90091	999	0	2021	19	United Mine Workers of America Health & Retirement	UMWA Funds		UMWA Funds	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.		UMWAFUNDS.ORG	0	0	2			0					3	0	0			
H0001	001	0	2021	0	Original Medicare				1	0	0																			0		0	0	0	0	0	0				0	www.medicare.gov	0	0	2	Locate <a href="http://www.medicare.gov/physiciancompare" target="_blank">Medicare participating physicians</a> in your area.	Localizar a <a href="http://www.medicare.gov/physiciancompare" target="_blank">los médicos participantes de Medicare</a> en su área.	0	<ul><li>If you have a Medigap (Medicare Supplement Insurance) policy, your costs may be lower for some benefits.</li><li>If you receive Medicaid benefits from your State, your costs may be lower for some benefits.</li></ul>	<ul><li>Si tiene una póliza Medigap (Seguro suplementario a Medicare), los costos que tenga que pagar por ciertos beneficios podrían ser menores.</li><li>Si recibe beneficios de Medicaid de su estado, sus costos pueden ser menos para algunos beneficios.</li></ul>			3	0	0			
H0022	001	0	2021	48	Buckeye Health Plan - MyCare Ohio (Medicare-Medicaid Plan)	CL, CU, FU, GE, GR, LA, LO, LU, ME, MO, OT, WO		CL, CU, FU, GE, GR, LA, LO, LU, ME, MO, OT, WO	1	0	0	4349 Easton Way	Suite 300	Columbus	OH	43219				4349 Easton Way	Suite 300	Columbus	OH	43219				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	mmp.buckeyehealthplan.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	mmp.buckeyehealthplan.com/findadoctor	mmp.buckeyehealthplan.com/findadoctor	mmp.buckeyehealthplan.com/formulary
H0028	007	0	2021	01	Humana Gold Plus SNP-DE H0028-007 (HMO D-SNP)	Omaha		Omaha	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	011	0	2021	01	Humana Gold Plus H0028-011 (HMO)	Heartland		Heartland	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	013	0	2021	01	Humana Gold Plus H0028-013 (HMO)	Wichita area		Wichita area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	014	0	2021	01	Humana Gold Plus H0028-014 (HMO)	St. Louis Metro area		St. Louis Metro area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	015	0	2021	01	Humana Gold Plus SNP-DE H0028-015 (HMO D-SNP)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	016	0	2021	01	Humana Gold Plus H0028-016 (HMO)	Springfield/Joplin		Springfield/Joplin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	017	0	2021	01	Humana Gold Plus H0028-017 (HMO)	Kansas City		Kansas City	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	018	0	2021	01	Humana Value Plus H0028-018 (HMO)	Select Counties in Kansas		Select Counties in Kansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $410.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $410.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	019	0	2021	01	Humana Gold Plus H0028-019 (HMO)	Albuquerque Metro Area		Albuquerque Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	021	0	2021	01	Humana Gold Plus H0028-021 (HMO)	Pima and Pinal Counties		Pima and Pinal Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	023	0	2021	01	Humana Gold Plus H0028-023 (HMO)	Yavapai, La Paz, Mohave, and Maricopa Counties		Yavapai, La Paz, Mohave, and Maricopa Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	024	0	2021	01	Humana Gold Plus H0028-024 (HMO)	La Paz and Mohave counties		La Paz and Mohave counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	025	1	2021	01	Humana Gold Plus H0028-025 (HMO)	Colorado		Denver Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	025	2	2021	01	Humana Gold Plus H0028-025 (HMO)	Colorado		North and South Colorado Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	027	0	2021	01	Humana Gold Plus H0028-027 (HMO)	Maricopa County		Maricopa County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	028	0	2021	01	Humana Gold Plus H0028-028 (HMO)	Maricopa and Yavapai Counties		Maricopa and Yavapai Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	029	0	2021	01	Humana Gold Plus H0028-029 (HMO)	Corpus Christi Metro Area		Corpus Christi Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	030	0	2021	01	Humana Gold Plus H0028-030 (HMO)	San Antonio Metro Area		San Antonio Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	031	0	2021	01	Humana Gold Plus SNP-DE H0028-031 (HMO D-SNP)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	032	0	2021	01	Humana Gold Plus SNP-DE H0028-032 (HMO D-SNP)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	033	0	2021	01	Humana Gold Plus SNP-DE H0028-033 (HMO D-SNP)	Fort Bend, Harris and Montgomery counties		Fort Bend, Harris and Montgomery counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	034	0	2021	01	Humana Gold Plus SNP-DE H0028-034 (HMO D-SNP)	El Paso County		El Paso County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	035	0	2021	01	Humana Gold Plus H0028-035 (HMO)	El Paso County		El Paso County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	036	0	2021	01	Humana Gold Plus SNP-DE H0028-036 (HMO D-SNP)	Corpus Christi/San Antonio area		Corpus Christi/San Antonio area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	037	0	2021	01	Humana Gold Plus H0028-037 (HMO)	Bastrop, Hays, Travis and Williamson counties		Bastrop, Hays, Travis and Williamson counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	039	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Corpus Christi Metro Area		Corpus Christi Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	041	0	2021	01	Humana Gold Plus H0028-041 (HMO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	042	0	2021	01	Humana Gold Plus H0028-042 (HMO)	Houston Metro Area		Houston Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	043	1	2021	01	Humana Gold Plus H0028-043 (HMO)	Dallas area		Dallas area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	043	2	2021	01	Humana Gold Plus H0028-043 (HMO)	Dallas area		Dallas area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	044	0	2021	01	Humana Gold Plus SNP-DE H0028-044 (HMO D-SNP)	Hays, Travis and Williamson counties		Hays, Travis and Williamson counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	045	0	2021	01	Humana Gold Plus SNP-DE H0028-045 (HMO D-SNP)	Cameron, Hidalgo and Willacy counties		Cameron, Hidalgo and Willacy counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	046	0	2021	01	Humana Gold Plus H0028-046 (HMO)	Cameron, Hidalgo and Willacy counties		Cameron, Hidalgo and Willacy counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	047	0	2021	01	Humana Gold Plus H0028-047 (HMO)	Colorado		Colorado	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	048	1	2021	01	Humana Gold Plus H0028-048 (HMO)	Honolulu, Kauai and Maui counties		Honolulu County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	048	2	2021	01	Humana Gold Plus H0028-048 (HMO)	Honolulu, Kauai and Maui counties		Kauai and Maui counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	801	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	802	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	804	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0028	805	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0029	801	0	2021	01	Allwell Group (HMO)	Pierce and Spokane Counties		Pierce and Spokane Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.coordinatedcarehealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	allwell.coordinatedcarehealth.com/findadoctor	allwell.coordinatedcarehealth.com/findadoctor	allwell.coordinatedcarehealth.com/formulary
H0029	802	0	2021	01	Allwell Group (HMO)	Pierce and Spokane Counties		Pierce and Spokane Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.coordinatedcarehealth.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	allwell.coordinatedcarehealth.com/findadoctor	allwell.coordinatedcarehealth.com/findadoctor	allwell.coordinatedcarehealth.com/formulary
H0029	803	0	2021	01	Allwell Group (HMO)	Pierce and Spokane Counties		Pierce and Spokane Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.coordinatedcarehealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	allwell.coordinatedcarehealth.com/findadoctor	allwell.coordinatedcarehealth.com/findadoctor	allwell.coordinatedcarehealth.com/formulary
H0034	001	0	2021	01	Hamaspik Medicare Select (HMO D-SNP)	New York City metro, Hudson Valley, Albany metro	Hamaspik Seleccion de Medicare (HMO D-SNP)	New York City metro, Hudson Valley, Albany metro	1	0	0	58 Route 59, Suite #1		Monsey	NY	10952		info@hamaspik.com	info@hamaspik.com	58 Route 59, Suite #1		Monsey	NY	10952		info@hamaspik.com	info@hamaspik.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.hamaspik.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.hamaspik.com	www.hamaspik.com	www.hamaspik.com
H0034	002	0	2021	01	Hamaspik Medicare Choice (HMO D-SNP)	NYC Metro area, Hudson Valley, Albany Metro area	Eleccion de Medicare de Hamaspik (HMO D-SNP)	NYC Metro area, Hudson Valley, Albany Metro area	1	0	0	58 Route 59, Suite #1		Monsey	NY	10952		info@hamaspik.com	info@hamaspik.com	58 Route 59, Suite #1		Monsey	NY	10952		info@hamaspik.com	info@hamaspik.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.hamaspik.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.hamaspik.com	www.hamaspik.com	www.hamaspik.com
H0062	001	0	2021	01	Allwell Medicare (HMO)	San Antonio, El Paso & Corpus Christi Areas		San Antonio, El Paso & Corpus Christi Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H0062	002	0	2021	01	Allwell Medicare (HMO)	Dallas Metro		Dallas Metro	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H0062	003	0	2021	01	Allwell Medicare (HMO)	Rio Grande Valley Area		Rio Grande Valley Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H0062	801	0	2021	01	Allwell Group (HMO)	Texas		Texas	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H0062	802	0	2021	01	Allwell Group (HMO)	Texas		Texas	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H0062	803	0	2021	01	Allwell Group (HMO)	Texas		Texas	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H0074	001	0	2021	04	WellCare Premier (PPO)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0088	001	0	2021	04	WellCare Premier (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0088	002	0	2021	04	WellCare Absolute (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0104	012	0	2021	04	Blue Advantage Complete (PPO)	State of Alabama		State of Alabama	1	0	0	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	014	0	2021	04	Blue Advantage Complete (PPO)	Birmingham/Mobile		Birmingham/Mobile	1	0	0	450 Riverchase Parkway East		Birmingham	AL	35173				450 Riverchase Parkway East		Birmingham	AL	35173				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	015	0	2021	04	Blue Advantage Premier (PPO)	State of Alabama		State of Alabama	1	0	0	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	801	0	2021	04	Blue Advantage Employer Group Plan 801 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	802	0	2021	04	Blue Advantage Employer Group Plan 802 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	804	0	2021	04	Blue Advantage Employer Group Plan 804 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	805	0	2021	04	Blue Advantage Employer Group Plan 805 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3108002000000000000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	806	0	2021	04	Blue Advantage Employer Group Plan 806 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	807	0	2021	04	Blue Advantage Employer Group Plan 807 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244				450 Riverchase Parkway East		Birmingham	AL	35244				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	808	0	2021	04	Blue Advantage Employer Group Plan 808 (PPO)	State of Alabama		State of Alabama	1	3	1	450 Riverchase Parkway		Birmingham	AL	35244				450 Riverchase Parkway		Birmingham	AL	35244				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0104	809	0	2021	04	Blue Advantage Employer Group Plan 809 (PPO)	State of Alabma		State of Alabma	1	3	1	450 Riverchase Parkway		Birmingham	AL	35244				450 Riverchase Parkway		Birmingham	AL	35244				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsalmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.bcbsalmedicare.com	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html	www.bcbsalmedicare.com/sales/plans/blueadvantage/tools.html
H0105	001	0	2021	20	The Methodist Oaks d.b.a. The Oaks PACE (PACE)	Rural South Carolina	The Methodist Oaks d.b.a. The Oaks PACE (PACE)	Rural South Carolina	1	3	0									153 Founders Court		Orangeburg	SC	29118		etill@theoakssc.com	diane.johnson@theoakssc.com	2000000000207001700307001700407001700507001700607001700000000000	2000000000207001700307001700407001700507001700607001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.theoakspace.com	0	0	1			0					3	0	0	http://www.theoakspace.com	http://www.theoakspace.com	www.groveparkpharmacy.com
H0105	002	0	2021	20	The Methodist Oaks d.b.a. The Oaks PACE (PACE)	Rural South Carolina	The Methodist Oaks d.b.a. The Oaks PACE (PACE)	Rural South Carolina	1	3	0									153 Founders Ct		Orangeburg	SC	29118		etill@theoakssc.com	diane.johnson@theoakssc.com	2000000000207001700307001700407001700507001700607001700000000000	2000000000207001700307001700407001700507001700607001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.theoakspace.com	0	0	1			0					3	0	0	http://www.theoakspace.com	http://www.theoakspace.com	www.groveparkpharmacy.com
H0107	003	0	2021	04	Blue Cross Medicare Advantage Classic (PPO)	Montana		Montana	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluemt.com/mapd	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluemt.com/providers	www.getbluemt.com/pharmacies	www.getbluemt.com/mapd/druglist
H0107	004	0	2021	04	Blue Cross Medicare Advantage Optimum (PPO)	Montana		Montana	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluemt.com/mapd	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluemt.com/mapd/providers	www.getbluemt.com/mapd/pharmacies	www.getbluemt.com/mapd/druglist
H0107	801	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Montana		Montana	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluemt.com/mapd	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	getbluemt.com/mapd/providers	www.getbluemt.com/pharmacies	www.getbluemt.com/mapd/druglist
H0107	802	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Montana		Montana	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluemt.com/mapd	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	getbluemt.com/mapd/providers	www.getbluemt.com/pharmacies	www.getbluemt.com/mapd/druglist
H0107	803	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Montana		State of Montana	1	3	1	PO Box 4555		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluemt.com/mapd	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	getbluemt.com/mapd/providers	www.getbluemt.com/pharmacies	www.getbluemt.com/mapd/druglist
H0107	804	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Montana		State of Montana	1	3	1	PO Box 4555		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.getbluemt.com/mapd	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.getbluemt.com/providers	www.getbluemt.com/pharmacies	www.getbluemt.com/mapd/druglist
H0111	001	0	2021	04	WellCare Premier (PPO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0111	002	0	2021	04	WellCare Prime (PPO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0111	003	0	2021	04	WellCare Flex Complete (PPO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0111	004	0	2021	04	WellCare Imperial (PPO D-SNP)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0111	005	0	2021	04	WellCare Endurance (PPO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0112	001	0	2021	20	Palm Beach PACE (PACE)	Palm Beach County (partial)		Palm Beach County (partial)	1	3	0									4847 David S. Mack Dr.		West Palm Beach	FL	33417		ASadowsky@MorseLife.org	ASadowsky@MorseLife.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MorseLife.org	0	0	1			0					3	0	0		MorseLife.org	N/A
H0112	002	0	2021	20	Palm Beach PACE (PACE)	Palm Beach County (partial)		Palm Beach County (partial)	1	3	0									4847 David S. Mack Dr.		West Palm Beach	FL	33417		ASadowsky@MorseLife.org	ASadowsky@MorseLife.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MorseLife.org	0	0	1			0					3	0	0		MorseLife.org	N/A
H0137	001	0	2021	48	Commonwealth Care Alliance (Medicare-Medicaid Plan)	BAR BRI ESS FRA HMD HMP MID NOR PLY SUF WOR		BAR BRI ESS FRA HMD HMP MID NOR PLY SUF WOR	1	0	0	30 Winter Street		Boston	MA	02108				30 Winter Street		Boston	MA	02108				2108001800208002000308002000408002000508002000608002000708001800	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.commonwealthonecare.org	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.commonwealthcarealliance.org	http://www.commonwealthcarealliance.org/members/pharmacy-program	http://www.commonwealthcarealliance.org/members/pharmacy-program/formulary-2021
H0148	001	0	2021	48	Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)	San Diego County	Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)	San Diego County	1	0	0	601 Potrero Grande Dr.		Monterey Park	CA	91755				601 Potrero Grande Dr.		Monterey Park	CA	91755				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	blueshieldca.com/promise/calmediconnect	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	blueshieldca.com/promise/calmediconnect	blueshieldca.com/promise/calmediconnect	blueshieldca.com/promise/calmediconnect
H0148	002	0	2021	48	Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)	Los Angeles County	Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)	Los Angeles County	1	0	0	601 Potrero Grande Dr.		Monterey Park	CA	91755				601 Potrero Grande Dr.		Monterey Park	CA	91755				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	blueshieldca.com/promise/calmediconnect	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	blueshieldca.com/promise/calmediconnect	blueshieldca.com/promise/calmediconnect	blueshieldca.com/promise/calmediconnect
H0154	008	0	2021	01	VIVA Medicare Select (HMO)	Northwest, Central, and South Alabama	VIVA Medicare Select (HMO)	Northwest, Central, and South Alabama	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/medicare/MemberResources/#ProviderNetwork	http://www.vivamedicaremember.com/Download.aspx?ID=992&Type=doc	http://www.vivamedicaremember.com/Download.aspx?ID=1326&Type=doc
H0154	011	0	2021	01	VIVA Medicare Premier (HMO)	Northwest, Central and South Alabama	VIVA Medicare Premier (HMO)	Northwest, Central and South Alabama	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	012	0	2021	01	VIVA Medicare Extra Value (HMO D-SNP)	Northwest, Central, and South Alabama	VIVA Medicare Extra Value (HMO D-SNP)	Northwest, Central, and South Alabama	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	014	0	2021	01	VIVA Medicare Me (HMO)	Central and Southeast Alabama	VIVA Medicare Me (HMO)	Central and Southeast Alabama	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	015	1	2021	01	VIVA Medicare Plus (HMO)	Northwest, Central, and South Alabama	VIVA Medicare Plus (HMO)	Northwest, Central and South Alabama	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	015	2	2021	01	VIVA Medicare Plus (HMO)	Northwest, Central, and South Alabama	VIVA Medicare Plus (HMO)	Ft Payne, Troy, Jasper, Russellville Area	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	016	0	2021	01	VIVA Medicare Prime (HMO)	Northwest, Central and South Alabama	VIVA Medicare Prime (HMO)	Northwest, Central and South Alabama	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	017	0	2021	01	VIVA Medicare Classic (HMO)	Limestone, Madison, and Morgan Counties	VIVA Medicare Classic (HMO)	Limestone, Madison, and Morgan Counties	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	018	0	2021	01	VIVA Medicare Preferred (HMO)	Limestone, Madison, and Morgan Counties	VIVA Medicare Preferred (HMO)	Limestone, Madison, and Morgan Counties	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/#PharmacyDirectories	www.vivahealth.com/Medicare/#Formularies
H0154	019	0	2021	01	VIVA Medicare Extra Care (HMO D-SNP)	Limestone, Madison, and Morgan Counties	VIVA Medicare Extra Care (HMO D-SNP)	Limestone, Madison, and Morgan Counties	1	0	0	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	801	0	2021	01	VIVA Medicare Group Plan with Rx (CY) (HMO)	State of Alabama	VIVA Medicare Group Plan with Rx (CY) (HMO)	State of Alabama	1	3	1	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0154	802	0	2021	01	VIVA Medicare Group Plan (no Rx) (HMO)	State of Alabama	VIVA Medicare Group Plan (no Rx) (HMO)	State of Alabama	1	3	1	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	http://www.vivamedicaremember.com/Download.aspx?ID=992&Type=doc	http://www.vivamedicaremember.com/Download.aspx?ID=1326&Type=doc
H0154	803	0	2021	01	VIVA Medicare Plus Group Plan with Rx (not CY) (HMO)	State of Alabama	VIVA Medicare Group Plan with Rx (not CY) (HMO)	State of Alabama	1	3	1	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	417 20th St North	Suite 1100	Birmingham	AL	35203		lhey@uabmc.edu	tmize@uabmc.edu	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vivahealth.com/Medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vivahealth.com/Medicare/MemberResources/#ProviderNetwork	www.vivahealth.com/Medicare/MemberResources/#PharmacyDirectories	www.vivahealth.com/Medicare/MemberResources/#Formularies
H0169	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Iowa		Select Counties in Iowa	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0169	002	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0169	003	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Nebraska		Select Counties in Nebraska	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0169	004	0	2021	02	UnitedHealthcare Dual Complete LP1 (HMO-POS D-SNP)	Select Counties in Kansas		Select Counties in Kansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCCommunityPlan.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0174	002	0	2021	01	WellCare TexanPlus Classic (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	003	0	2021	01	WellCare TexanPlus Classic (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	004	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	005	0	2021	02	WellCare Value (HMO-POS)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	006	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	007	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	008	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	009	0	2021	01	WellCare Compass (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0174	010	0	2021	01	WellCare Value (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0192	001	0	2021	48	AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan)	Wayne and Macomb Counties		Wayne and Macomb Counties	1	0	0	200 Stevens Drive		Philadelphia	PA	19113				200 Stevens Drive		Philadelphia	PA	19113				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.amerihealthcaritasvipcareplus.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.amerihealthcaritasvipcareplus.com	www.amerihealthcaritasvipcareplus.com	www.amerihealthcaritasvipcareplus.com
H0216	001	0	2021	20	PACE Iowa (PACE)	Mills, Harrison, and Pottawattamie Counties		Mills, Harrison, and Pottawattamie Counties	1	3	0									1702 North 16th Street		Council Bluffs	IA	51501		sgroth@immanuel.com	sgroth@immanuel.com	3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Immanuel.com	0	0	1			0					3	0	0		www.immanuel.com	www.immanuel.com
H0216	002	0	2021	20	PACE Iowa (PACE)	Counties: PK, MR, SR, BN, DA, MD, JP, WA, MA		Counties: PK, MR, SR, BN, DA, MD, JP, WA, MA	1	3	0									7700 Hickman Road		Windsor Heights	IA	50324		sgroth@immanuel.com	sgroth@immanuel.com	3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Immanuel.com	0	0	1			0					3	0	0		www.immanuel.com	www.immanuel.com
H0235	001	0	2021	20	PACE of NE IN - Dual Eligible (PACE)	Allen		Allen	1	3	0									8101 N Jefferson Blvd		Fort Wayne	IN	46804		ashapiro@agingihs.org	ashapiro@agingihs.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.agingihs.org	0	0	1			0					3	0	0		https://agingihs.org	https://agingihs.org/
H0235	002	0	2021	20	PACE of NE IN - Medicare Only (PACE)	Allen		Allen	1	3	0									8101 N Jefferson Blvd		Fort Wayne	IN	46804		ashapiro@agingihs.org	ashapiro@agingihs.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.agingihs.org	0	0	1			0					3	0	0		https://agingihs.org	https://agingihs.org/
H0247	001	0	2021	20	AllCare PACE - Dual Eligible (PACE)	Josephine and Jackson counties		Josephine and Jackson counties	1	3	0									2166 NW Vine Street		Grants Pass	OR	97526				5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.allcarehealth.com	0	0	1			0					3	0	0	www.allcarehealth.com	www.allcarehealth.com	www.allcarehealth.com
H0247	002	0	2021	20	AllCare PACE - Medicare Only (PACE)	Josephine and Jackson counties		Josephine and Jackson counties	1	3	0									2166 NW Vine Street		Grants Pass	OR	97526				5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.allcarehealth.com	0	0	1			0					3	0	0	www.allcarehealth.com	www.allcarehealth.com	www.allcarehealth.com
H0251	002	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0251	004	0	2021	01	UnitedHealthcare Dual Complete ONE (HMO D-SNP)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0251	005	0	2021	01	UnitedHealthcare Dual Complete ONE Plus (HMO D-SNP)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0270	001	0	2021	04	WellCare Premier (PPO)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0270	002	0	2021	04	WellCare Imperial (PPO D-SNP)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0271	002	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Ada, Canyon, Gem, and Payette counties		Ada, Canyon, Gem, and Payette counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	003	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	004	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select Counties in Illinois		Select Counties in Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	005	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	006	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Select Counties in Maine		Select Counties in Maine	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	007	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select counties in New Hampshire		Select counties in New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	008	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Graham, Santa Cruz, and Yavapai counties		Graham, Santa Cruz, and Yavapai counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	010	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select Counties in New Mexico		Select Counties in New Mexico	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	011	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Dona Ana, Grant, Hidalgo, Luna, Sierra counties		Dona Ana, Grant, Hidalgo, Luna, Sierra counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	012	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select counties in Vermont		Select counties in Vermont	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	013	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Select Counties in West Virginia		Select Counties in West Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	014	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	016	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	SC DSNP		SC DSNP	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	017	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select Counties in North Dakota		Select Counties in North Dakota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	018	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select Counties in South Dakota		Select Counties in South Dakota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	019	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Cook County		Cook County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	020	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Select counties in North Maine		Select counties in North Maine	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0271	022	0	2021	04	UnitedHealthcare Medicare Advantage Assure (PPO)	Select counties in Oregon		Select counties in Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0292	001	0	2021	01	Humana Community (HMO)	Select counties in Northern Kentucky		Select counties in Northern Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0292	002	0	2021	01	Humana Gold Plus H0292-002 (HMO)	Select counties in Northern Kentucky		Select counties in Northern Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0294	002	0	2021	04	UnitedHealthcare Medicare Advantage Assist (PPO C-SNP)	Select counties in Wisconsin	UnitedHealthcare MedicareComplete Assist (PPO C-SNP)	Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0294	004	0	2021	04	AARP Medicare Advantage Open Plan 1 (PPO)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0294	010	0	2021	04	UnitedHealthcare Medicare Advantage Assist (PPO C-SNP)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0294	011	0	2021	04	AARP Medicare Advantage Open (PPO)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $385.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $385.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0294	012	0	2021	04	AARP Medicare Advantage Open Premier (PPO)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0294	014	0	2021	04	AARP Medicare Advantage Patriot Plan 1 (PPO)	Select Wisconsin Counties		Select Wisconsin Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0294	015	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Select counties in Eastern Wisconsin		Select counties in Eastern Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0294	016	0	2021	04	AARP Medicare Advantage Open Plan 2 (PPO)	Select Counties in South-Central Wisconsin		Select Counties in South-Central Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0294	017	0	2021	04	AARP Medicare Advantage Open (PPO)	Wayne County		Wayne County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0302	001	0	2021	01	Blue Medicare Advantage Plus (HMO)	Maricopa County and partial Pinal County		Maricopa County and partial Pinal County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H0302	006	0	2021	01	Blue Medicare Advantage Classic (HMO)	Maricopa County and partial Pinal County		Maricopa County and partial Pinal County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H0302	008	0	2021	01	Blue Medicare Advantage Classic (HMO)	Pima County		Pima County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H0302	009	0	2021	01	Blue Medicare Advantage Standard (HMO)	Santa Cruz County		Santa Cruz County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H0302	801	0	2021	01	Blue Medicare Advantage Employer Plan (HMO)	Arizona		Arizona	1	3	1	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com									4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H0321	002	0	2021	01	UnitedHealthcare Dual Complete LP (HMO D-SNP)	Select counties in Arizona	UnitedHealthcare Dual Complete (HMO D-SNP)	Select counties in Arizona	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0321	004	0	2021	01	UnitedHealthcare Dual Complete ONE (HMO D-SNP)	Select counties in Arizona	UnitedHealthcare Dual Complete ONE (HMO D-SNP)	Select counties in Arizona	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0332	001	0	2021	01	KelseyCare Advantage Essential (HMO)	BO,FB,FV,HR, and MQ counties		BO,FB,FV,HR, and MQ counties	1	0	0	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	002	0	2021	01	KelseyCare Advantage Rx (HMO)	BO,FB,FV,HR, and MQ counties		BO,FB,FV,HR, and MQ counties	1	0	0	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	003	0	2021	02	KelseyCare Advantage Essential+Choice (HMO-POS)	BO,FB,FV,HR, and MQ counties		BO,FB,FV,HR, and MQ counties	1	0	0	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	004	0	2021	02	KelseyCare Advantage Rx+Choice (HMO-POS)	BO,FB,FV,HR, and MQ counties		BO,FB,FV,HR, and MQ counties	1	0	0	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	007	0	2021	02	KelseyCare Advantage Essential Select (HMO-POS)	AU,CH,GM,LB,SJ,WA,WL, and WH counties		AU,CH,GM,LB,SJ,WA,WL, and WH counties	1	0	0	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	008	0	2021	02	KelseyCare Advantage Rx Select (HMO-POS)	AU,CH,GM,LB,SJ,WA,WL, and WH counties		AU,CH,GM,LB,SJ,WA,WL, and WH counties	1	0	0	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	801	0	2021	01	KelseyCare Advantage Essential Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	803	0	2021	01	KelseyCare Advantage Rx Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	804	0	2021	01	KelseyCare Advantage Essential+Choice Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	805	0	2021	01	KelseyCare Advantage Rx+Choice Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	806	0	2021	01	KelseyCare Advantage Essential Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	807	0	2021	01	KelseyCare Advantage Rx Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	808	0	2021	01	KelseyCare Advantage Essential+Choice Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	809	0	2021	01	KelseyCare Advantage Rx+Choice Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	810	0	2021	01	KelseyCare Advantage Rx Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	811	0	2021	01	KelseyCare Advantage Rx Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	812	0	2021	01	KelseyCare Advantage Rx Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	813	0	2021	01	KelseyCare Advantage RX Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584				11511 Shadow Creek Parkway		Pearland	TX	77584				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0332	814	0	2021	01	KelseyCare Advantage Essential Retiree (HMO)	Texas		Texas	1	3	1	11511 Shadow Creek Parkway		Pearland	TX	77584												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.kelseycareadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Kelseycareadvantage.com	www.kelseycareadvantage.com	www.kelseycareadvantage.com
H0336	001	0	2021	48	Humana Gold Plus Integrated H0336-001 (Medicare-Medicaid Plan)	Illinois		Illinois	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.humana.com/medicare/medicaid-dual/illinois/	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.humana.com/medicare/medicaid-dual/illinois/help/	www.humana.com/medicare/medicaid-dual/illinois/pharmacy/	www.humana.com/medicare/medicaid-dual/illinois/pharmacy/
H0342	001	0	2021	04	CarePartners Access (PPO)	Most of Connecticut		Most of Connecticut	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.carepartnersct.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/insurerCode=TUFTS_I&brandCode=THPMPCPCT&pr	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/insurerCode=TUFTS_I&brandCode=THPMPCPCT&pr	www.carepartnersct.com/drug-search
H0351	038	0	2021	01	Allwell CHF/Diabetes Medicare (HMO C-SNP)	Maricopa and Pinal Counties	Allwell CHF/Diabetes Medicare (HMO C-SNP)	Maricopa and Pinal Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0351	052	0	2021	01	Allwell Medicare Premier II (HMO)	Maricopa, Pima and Pinal Counties	Allwell Medicare (HMO)	Maricopa, Pima and Pinal Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0351	053	0	2021	01	Allwell Medicare Premier II (HMO)	Cochise, Santa Cruz, Yavapai, Yuma counties		Cochise, Santa Cruz, Yavapai, Yuma counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0351	054	0	2021	01	Allwell Medicare Boost (HMO)	Cochise, Santa Cruz, Yuma counties		Cochise, Santa Cruz, Yuma counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0351	801	0	2021	01	Allwell CoCare (HMO)	All AZ Counties	Allwell CoCare (HMO)	All AZ Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0351	803	0	2021	01	Allwell CoCare (HMO)	All AZ Counties	Allwell CoCare (HMO)	All AZ Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0351	804	0	2021	01	Allwell CoCare (HMO)	All AZ Counties	Allwell CoCare (HMO)	All AZ Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H0354	001	0	2021	01	Cigna Preferred Medicare (HMO)	Maricopa Co. and Select Zip Codes in Pinal Co.	Cigna Preferred Medicare (HMO)	Maricopa Co. and Select Zip Codes in Pinal Co.	1	0	0	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0354	024	0	2021	01	Cigna Preferred Medicare (HMO)	Pima County	Cigna Preferred Medicare (HMO)	Pima County	1	0	0	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0354	027	0	2021	01	Cigna Achieve Medicare (HMO C-SNP)	Maricopa Co. and Select Zip Codes in Pinal Co.	Cigna Achieve Medicare (HMO C-SNP)	Maricopa Co. and Select Zip Codes in Pinal Co.	1	0	0	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0354	028	0	2021	01	Cigna Alliance Medicare (HMO)	Maricopa Co. and select zip codes in Pinal Co.	Cigna Alliance Medicare (HMO)	Maricopa Co. and select zip codes in Pinal Co.	1	0	0	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0354	804	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide AZ	Cigna Preferred Medicare (HMO)	Statewide AZ	1	3	1	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0354	805	0	2021	01	Cigna Preferred Medicare FY (HMO)	Statewide AZ	Cigna Preferred Medicare FY (HMO)	Statewide AZ	1	3	1	P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		P.O. Box 29030	Attention: Medicare Customer Service	Phoenix	AZ	85038		seniors@cigna.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0363	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	CO service areas		CO service areas	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H0390	001	0	2021	20	PACE of Southwest Michigan - Dual (PACE)	PACE of Southwest Michigan - Dual		PACE of Southwest Michigan - Dual	1	3	0									2900 Lakeview Ave		St. Joseph	MI	49085				2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.paceswmi.org/	0	0	1			0					3	0	0		www.paceswmi.org	www.paceswmi.org
H0390	002	0	2021	20	PACE of Southwest Michigan - Medicare Only (PACE)	PACE of Southwest Michigan - Medicare Only		PACE of Southwest Michigan - Medicare Only	1	3	0									2900 Lakeview Ave		St. Joseph	MI	49085				2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.paceswmi.org/	0	0	1			0					3	0	0		www.paceswmi.org	www.paceswmi.org
H0422	001	0	2021	02	Care Core: M Health Fairview & North Memorial (HMO-POS)	Twin Cities Metropolitan Area: 8 Counties		Twin Cities Metropolitan Area: 8 Counties	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H0422	002	0	2021	02	Care Advantage: M Health Fairview & North Memorial (HMO-POS)	Twin Cities Metropolitan Area: 8 Counties		Twin Cities Metropolitan Area: 8 Counties	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H0423	001	0	2021	01	MetroPlus Advantage Plan (HMO D-SNP)	NYC - All five boroughs		NYC - All five boroughs	1	0	0	50 Water Street, 7th Floor		New York	NY	10004				50 Water Street, 7th Floor		New York	NY	10004				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.metroplusmedicare.org	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.metroplusmedicare.org	www.caremark.com	https://www.metroplus.org/member-services/formularies
H0423	004	0	2021	01	MetroPlus Platinum Plan (HMO)	NYC - All five boroughs		NYC - All five boroughs	1	0	0	50 Water Street, 7th Floor		New York	NY	10004				50 Water Street, 7th Floor		New York	NY	10004				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.metroplusmedicare.org	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	1	www.metroplusmedicare.org	www.caremark.com	https://www.metroplus.org/member-services/formularies
H0423	007	0	2021	01	MetroPlus UltraCare (HMO D-SNP)	NYC - All five boroughs		NYC - All five boroughs	1	0	0	50 Water Street, 7th Floor		New York	NY	10004				50 Water Street, 7th Floor		New York	NY	10004				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.metroplusmedicare.org	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.metroplusmedicare.org	www.caremark.com	https://www.metroplus.org/member-services/formularies
H0432	001	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Northern Alabama		Northern Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0432	002	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Northern Alabama		Northern Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0432	003	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Southern Alabama		Southern Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0432	004	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Southern Alabama		Southern Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0432	009	0	2021	01	UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0432	010	0	2021	01	AARP Medicare Advantage Walgreens (HMO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0432	012	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Entire state of Alabama		Entire state of Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0439	002	0	2021	01	Cigna TotalCare (HMO D-SNP)	Georgia	Cigna TotalCare (HMO D-SNP)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		LetUsHelpYou@HealthSpring.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		LetUsHelpYou@HealthSpring.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	003	1	2021	01	Cigna Preferred GA Medicare (HMO)	Georgia	Cigna Preferred GA Medicare (HMO)	Georgia Metro/Athens	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	003	2	2021	01	Cigna Preferred GA Medicare (HMO)	Georgia	Cigna Preferred GA Medicare (HMO)	Georgia Gainesville/Rome	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	006	0	2021	02	Cigna Premier Medicare (HMO-POS)	Georgia	Cigna Premier Medicare (HMO-POS)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	007	0	2021	01	Cigna Preferred Medicare (HMO)	Georgia	Cigna Preferred Medicare (HMO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	008	0	2021	01	Cigna Preferred Medicare (HMO)	Georgia	Cigna Preferred Medicare (HMO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	009	0	2021	01	Cigna Preferred Medicare (HMO)	Georgia	Cigna Preferred Medicare (HMO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	010	0	2021	01	Cigna Preferred Medicare (HMO)	Georgia	Cigna Preferred Medicare (HMO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	011	0	2021	01	Cigna Preferred Medicare (HMO)	Georgia	Cigna Preferred Medicare (HMO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0439	801	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide GA	Cigna Preferred Medicare (HMO)	Statewide GA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0473	001	0	2021	04	HumanaChoice H0473-001 (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0473	003	0	2021	04	HumanaChoice H0473-003 (PPO)	Hays, Travis and Williamson counties		Hays, Travis and Williamson counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0473	004	0	2021	04	HumanaChoice H0473-004 (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0473	005	0	2021	04	HumanaChoice H0473-005 (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0473	006	0	2021	04	HumanaChoice SNP-DE H0473-006 (PPO D-SNP)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0477	001	0	2021	20	Serenity PACE Dual (PACE)	Serenity Pace Dual		Serenity Pace Dual	1	3	0									604 Cottage st		Springfield	MA	01104		rita.blanter@ihserv.org	rita.blanter@ihserv.org	2108001730208001730308001730408001730508001730608002030708002000	2108001730208001730308001730408001730508001730608001730708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.serenitypace.org	0	0	1			0					3	0	0		www.omnicare.com	www.pharmastarpbm.com
H0477	002	0	2021	20	Serenity PACE Medicare only (PACE)	Serenity PACE Medicare only		Serenity PACE Medicare only	1	3	0									604 Cottage st		Springfield	MA	01104		rita.blanter@ihserv.org	rita.blanter@ihserv.org	2108001730208001730308001730408001730508001730608001730708002000	2108001730208001730308001715408001730508001730608001730708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.serenitypace.org	0	0	1			0					3	0	0		www.omnicare.com	www.pharmastarpbm.com
H0480	001	0	2021	48	MeridianComplete (Medicare-Medicaid Plan)	Greater Detroit		Greater Detroit	1	0	0	1 Campus Martius	Suite 700	Detroit	MI	48226				1 Campus Martius	Suite 700	Detroit	MI	48226				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	https://corp.mhplan.com/	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	https://corp.mhplan.com/	https://corp.mhplan.com/	https://corp.mhplan.com/
H0482	001	0	2021	01	Ascension Complete Michigan Reward (HMO)	Genesee, Kalamazoo, and Saginaw Counties		Genesee, Kalamazoo, and Saginaw Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $390.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $390.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/mi-findadoctor	ascensioncomplete.com/mi-findadoctor	ascensioncomplete.com/mi-formulary
H0482	002	0	2021	01	Ascension Complete Michigan Secure (HMO)	Genesee, Kalamazoo, and Saginaw Counties		Genesee, Kalamazoo, and Saginaw Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/mi-findadoctor	ascensioncomplete.com/mi-findadoctor	ascensioncomplete.com/mi-formulary
H0504	015	0	2021	01	Blue Shield 65 Plus (HMO)	Los Angeles and Orange Counties	Blue Shield 65 Plus (HMO)	Los Angeles and Orange Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	017	0	2021	01	Blue Shield 65 Plus (HMO)	San Bernardino County	Blue Shield 65 Plus (HMO)	San Bernardino County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	021	0	2021	01	Blue Shield 65 Plus Plan 2 (HMO)	Los Angeles and Orange Counties	Blue Shield 65 Plus Plan 2 (HMO)	Los Angeles and Orange Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is only offered in certain zip codes.  Please ask the plan if it is available in your zip code.</li></ul>	<ul><li>Este plan es ofrecido solamente en ciertos códigos postales. Por favor pregunte al plan si esta disponible en su área de código postal.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	026	0	2021	01	Blue Shield 65 Plus (HMO)	Riverside County	Blue Shield 65 Plus (HMO)	Riverside County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	028	0	2021	01	Blue Shield 65 Plus (HMO)	San Diego County	Blue Shield 65 Plus (HMO)	San Diego County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	029	0	2021	01	Blue Shield 65 Plus (HMO)	Ventura County	Blue Shield 65 Plus (HMO)	Ventura County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	031	0	2021	01	Blue Shield Inspire (HMO)	Fresno and Madera Counties	Blue Shield Inspire (HMO)	Fresno and Madera Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	037	0	2021	01	Blue Shield Inspire (HMO)	Sacramento County	Blue Shield Inspire (HMO)	Sacramento County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	038	0	2021	01	Blue Shield 65 Plus (HMO)	Kern County	Blue Shield 65 Plus (HMO)	Kern County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	039	0	2021	01	Blue Shield 65 Plus (HMO)	San Luis Obispo and Santa Barbara Counties	Blue Shield 65 Plus (HMO)	San Luis Obispo and Santa Barbara Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	040	0	2021	01	Blue Shield 65 Plus Choice Plan (HMO)	Riverside and San Bernardino Counties	Blue Shield 65 Plus Choice Plan (HMO)	Riverside and San Bernardino Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	041	0	2021	01	Blue Shield Inspire (HMO)	Alameda County	Blue Shield Inspire (HMO)	Alameda County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	042	0	2021	01	Blue Shield Inspire (HMO)	San Mateo County	Blue Shield Inspire (HMO)	San Mateo County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	043	0	2021	01	Blue Shield Inspire (HMO)	Los Angeles and Orange Counties	Blue Shield Inspire (HMO)	Los Angeles and Orange Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	044	0	2021	01	Blue Shield Vital (HMO)	Los Angeles and Orange Counties	Blue Shield Vital (HMO)	Los Angeles and Orange Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	045	0	2021	01	Blue Shield Vital (HMO)	Riverside and San Bernardino Counties	Blue Shield Vital (HMO)	Riverside and San Bernardino Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	046	0	2021	01	Blue Shield Inspire (HMO)	Santa Clara County	Blue Shield Inspire (HMO)	Santa Clara County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	047	0	2021	01	Blue Shield Inspire (HMO)	Merced/San Joaquin/Stanislaus Counties	Blue Shield Inspire (HMO)	Merced/San Joaquin/Stanislaus Counties	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	803	0	2021	01	Blue Shield 65 Plus (HMO)	MA-PD Employer Group Plan	Blue Shield 65 Plus (HMO)	MA-PD Employer Group Plan	1	3	1	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	804	0	2021	01	Blue Shield 65 Plus (HMO)	MA-PD Employer Group Plan	Blue Shield 65 Plus (HMO)	MA-PD Employer Group Plan	1	3	1	6300 Canoga Ave		Woodland HIlls	CA	91367				6300 Canoga Ave		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0504	805	0	2021	01	Blue Shield 65 Plus (HMO)	MA-Only Employer Group Plan	Blue Shield 65 Plus (HMO)	MA-Only Employer Group Plan	1	3	1	6300 Canoga Avenue		Woodland HIlls	CA	91367												5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H0523	002	0	2021	01	Aetna Medicare Select Plan (HMO)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0523	022	0	2021	01	Aetna Medicare Select Plan (HMO)	Riverside and San Bernardino Counties		Riverside and San Bernardino Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0523	031	0	2021	01	Aetna Medicare Select Plan (HMO)	Kern County		Kern County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0523	052	0	2021	01	Aetna Medicare Select Plan (HMO)	San Diego County		San Diego County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0523	061	0	2021	01	Aetna Medicare Prime Plan (HMO)	Los Angeles, Orange and San Bernardino Counties		Los Angeles, Orange and San Bernardino Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0523	801	0	2021	01	Aetna Medicare Plan (HMO)	California		California	1	3	1	151 Farmington Avenue		Hartford	CT	06156		FischerK@Aetna.com	HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0523	805	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	California		California	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0524	002	0	2021	01	Kaiser Permanente Senior Advantage B Only South (HMO)	Part B Only Southern California Area		Part B Only Southern California Area	3	3	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>Available to current members only.</li></ul>	<ul><li>Solamente disponible a socios activos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	003	0	2021	01	Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)	Los Angeles and Orange Counties Plan		Los Angeles and Orange Counties Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	008	0	2021	01	Kaiser Permanente Senior Advantage Solano (HMO)	Solano County Plan		Solano County Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	010	0	2021	01	Kaiser Permanente Senior Advantage B Only North (HMO)	Part B Only Northern California Area		Part B Only Northern California Area	3	3	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>Available to current members only.</li></ul>	<ul><li>Solamente disponible a socios activos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	013	0	2021	01	Kaiser Permanente Sr Adv Enhanced Sac., Sonoma (HMO)	Greater Sac and Sonoma County Plan - Enhanced		Greater Sac and Sonoma County Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	015	0	2021	01	Kaiser Permanente Senior Advantage Inland Empire (HMO)	Inland Empire Plan		Inland Empire Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	029	0	2021	01	Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)	Southern California Plan		Southern California Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	030	0	2021	01	Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP)	Northern California Plan		Northern California Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	031	0	2021	01	Kaiser Permanente Senior Advantage Marin San Mateo (HMO)	Marin and San Mateo Counties Plan		Marin and San Mateo Counties Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	032	0	2021	01	Kaiser Permanente Senior Advantage Alam., SF, Napa (HMO)	Alameda, Napa, and SF Counties Plan		Alameda, Napa, and SF Counties Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	033	0	2021	01	Kaiser Permanente Sr Adv Enhanced Contra Costa (HMO)	Contra Costa County Plan - Enhanced		Contra Costa County Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	034	0	2021	01	Kaiser Permanente Senior Advantage Ventura (HMO)	Ventura County Plan		Ventura County Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	035	0	2021	01	Kaiser Permanente Senior Advantage Enhanced Kern (HMO)	Kern County Plan - Enhanced		Kern County Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	036	0	2021	01	Kaiser Permanente Senior Advantage Basic Kern (HMO)	Kern County Plan - Basic		Kern County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	037	0	2021	01	Kaiser Permanente Senior Advantage San Diego (HMO)	San Diego County Plan		San Diego County Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	038	0	2021	01	Kaiser Permanente Senior Advantage Enhanced Fresno (HMO)	Greater Fresno Area Plan - Enhanced		Greater Fresno Area Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	039	0	2021	01	Kaiser Permanente Sr Adv Enhanced Santa Clara (HMO)	Santa Clara County Plan - Enhanced		Santa Clara County Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	040	0	2021	01	Kaiser Permanente Senior Advantage Enhanced Stanis (HMO)	Stanislaus County Plan - Enhanced		Stanislaus County Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	041	0	2021	01	Kaiser Permanente Senior Advantage Basic Stanis (HMO)	Stanislaus County Plan - Basic		Stanislaus County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	042	0	2021	01	Kaiser Permanente Senior Advantage Enhanced SnJoaq (HMO)	San Joaquin County Plan - Enhanced		San Joaquin County Plan - Enhanced	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	043	0	2021	01	Kaiser Permanente Senior Advantage Basic SnJoaq (HMO)	San Joaquin County Plan - Basic		San Joaquin County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	046	0	2021	01	Kaiser Permanente Senior Advantage Basic Fresno (HMO)	Greater Fresno Area Plan - Basic		Greater Fresno Area Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	051	0	2021	01	Kaiser Permanente Sr Advantage Basic Sac., Sonoma (HMO)	Greater Sac and Sonoma County Plan - Basic		Greater Sac and Sonoma County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	054	0	2021	01	Kaiser Permanente Senior Advantage Santa Cruz (HMO)	Santa Cruz County Plan		Santa Cruz County Plan	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	059	0	2021	01	Kaiser Permanente Senior Advantage Basic Alameda (HMO)	Alameda County Plan - Basic		Alameda County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	060	0	2021	01	Kaiser Permanente Senior Advantage Basic SF (HMO)	San Francisco County Plan - Basic		San Francisco County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	061	0	2021	01	Kaiser Permanente Sr Adv Basic Contra Costa (HMO)	Contra Costa County Plan - Basic		Contra Costa County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	062	0	2021	01	Kaiser Permanente Sr Adv Basic Santa Clara (HMO)	Santa Clara County Plan - Basic		Santa Clara County Plan - Basic	1	0	0	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	801	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Southern California Group Part A B		Southern California Group Part A B	1	3	1	1800 Harrison Street		Oakland	CA	94612												5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	802	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Northern California Group Part A B		Northern California Group Part A B	1	3	1	1800 Harrison Street		Oakland	CA	94612												5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	803	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Southern California Group B Only		Southern California Group B Only	1	3	1	1800 Harrison Street		Oakland	CA	94612												5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	804	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Northern California Group B Only		Northern California Group B Only	1	3	1	1800 Harrison Street		Oakland	CA	94612												5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	805	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Southern California Group Part A B Part D		Southern California Group Part A B Part D	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	806	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Northern California Group Part A B Part D		Northern California Group Part A B Part D	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	807	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Southern California Group Part B only  Part D		Southern California Group Part B only  Part D	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	808	0	2021	01	Kaiser Permanente Senior Advantage (HMO)	Northern California Group Part B only Part D		Northern California Group Part B only Part D	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	809	0	2021	01	FEHB Part AB with D (HMO)	Southern California Plan		Southern California Plan	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	810	0	2021	01	FEHB Part AB with D (HMO)	Northern California Plan		Northern California Plan	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	811	0	2021	01	FEHB Part B Only with D (HMO)	Southern California Plan		Southern California Plan	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0524	812	0	2021	01	FEHB Part B Only with D (HMO)	Northern California Plan		Northern California Plan	1	3	1	1800 Harrison Street		Oakland	CA	94612				1800 Harrison Street		Oakland	CA	94612				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0542	001	0	2021	20	AltaMed Health Services Corporation (PACE)	Los Angeles County		Los Angeles County	1	3	0									2040 Camfield Ave		Los Angeles	CA	90040		mzhughes@altamed.org	mzhughes@altamed.org	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.altamed.org	0	0	1			0					3	0	0		http://www.altamed.org/	http://www.altamed.org/
H0542	002	0	2021	20	AltaMed Health Services Corporation (PACE)	Los Angeles County		Los Angeles County	1	3	0									2040 Camfield Ave		Los Angeles	CA	90040		mzhughes@altamed.org	mzhughes@altamed.org	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.altamed.org	0	0	1			0					3	0	0		http://www.altamed.org/	http://www.altamed.org/
H0543	001	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Los Angeles county	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Los Angeles county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	013	0	2021	01	AARP Medicare Advantage SecureHorizons Value (HMO)	San Diego county	AARP Medicare Advantage SecureHorizons Value (HMO)	San Diego county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	019	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Kern county	AARP Medicare Advantage SecureHorizons (HMO)	Kern county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	022	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Ventura county	AARP Medicare Advantage SecureHorizons (HMO)	Ventura county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	028	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	San Mateo county	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	San Mateo county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	029	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Santa Clara county	AARP Medicare Advantage SecureHorizons (HMO)	Santa Clara county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	032	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Santa Barbara and San Luis Obispo counties	AARP Medicare AdvantageSecureHorizons Plan 1 (HMO)	Santa Barbara and San Luis Obispo counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $375.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $375.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	035	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Fresno, Kings and Madera counties	AARP Medicare Advantage SecureHorizons (HMO)	Fresno, Kings and Madera counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	036	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Stanislaus county	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Stanislaus county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	060	0	2021	01	AARP Medicare Advantage SecureHorizons Premier (HMO)	San Diego county	AARP Medicare Advantage SecureHorizons Premier (HMO)	San Diego county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	070	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Alameda and Contra Costa counties	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Alameda and Contra Costa counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	086	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Nevada county	AARP Medicare Advantage SecureHorizons (HMO)	Nevada county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	089	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Placer, Sacramento, and Yolo counties	AARP Medicare Advantage SecureHorizons (HMO)	Placer, Sacramento, and Yolo counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	121	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select Counties in Southern California	AARP Medicare Advantage Patriot (HMO)	Select Counties in Southern California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	138	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Orange county	AARP Medicare AdvantageSecureHorizons Plan 2 (HMO)	Orange county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	140	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Amador, El Dorado, Mendocino, Merced, Tulare	AARP Medicare Advantage SecureHorizons (HMO)	Amador, El Dorado, Mendocino, Merced, Tulare	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	144	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Riverside and San Bernardino counties	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Riverside and San Bernardino counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	145	0	2021	01	Sharp SecureHorizons Plan by UnitedHealthcare (HMO)	San Diego county	Sharp SecureHorizons Plan by UnitedHealthcare (HMO)	San Diego county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	146	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Placer, Sacramento, and Yolo counties	AARP Medicare Advantage SecureHorizons Focus (HMO)	Placer, Sacramento, and Yolo counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	147	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Stanislaus county	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Stanislaus county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	148	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Sonoma county	AARP Medicare Advantage SecureHorizons (HMO)	Sonoma county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	151	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Los Angeles county	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Los Angeles county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	152	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 4 (HMO)	San Diego county	AARP Medicare Advantage SecureHorizons Plan 4 (HMO)	San Diego county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	153	0	2021	01	UnitedHealthcare Medicare Advantage Assure (HMO)	Los Angeles, Orange, Riverside, and San Bernardino		Los Angeles, Orange, Riverside, and San Bernardino	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	158	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	San Mateo County		San Mateo County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	163	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Contra Costa County		Contra Costa County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	164	0	2021	01	AARP Medicare Advantage SecureHorizons Premier (HMO)	Los Angeles County		Los Angeles County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	165	0	2021	01	AARP Medicare Advantage SecureHorizons Premier (HMO)	Orange County		Orange County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	166	0	2021	01	AARP Medicare Advantage SecureHorizons Premier (HMO)	Riverside and San Bernardino Counties		Riverside and San Bernardino Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	167	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	San Luis Obispo County		San Luis Obispo County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	168	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Los Angeles County	AARP Medicare Advantage SecureHorizons Focus (HMO)	Los Angeles County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	169	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Orange County		Orange County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	170	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Riverside and San Bernardino County		Riverside and San Bernardino County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	172	0	2021	01	UnitedHealthcare Medicare Advantage Assure (HMO)	San Diego County		San Diego County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	173	0	2021	01	UnitedHealthcare Medicare Advantage Assure (HMO)	Kern County		Kern County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	175	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	San Francisco County		San Francisco County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	176	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Marin County		Marin County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	177	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	San Joaquin county		San Joaquin county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	178	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Santa Cruz County		Santa Cruz County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	179	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Solano County		Solano County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	183	0	2021	01	UnitedHealthcare Medicare Advantage Assure (HMO)	Select Counties in Northern California		Select Counties in Northern California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	185	0	2021	01	UnitedHealthcare Medicare Advantage Assure (HMO)	Select counties in Northern California		Select counties in Northern California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	188	0	2021	01	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Alameda County	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Alameda County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	189	0	2021	01	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Contra Costa County	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Contra Costa County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	191	0	2021	01	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	San Francisco County	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	San Francisco County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	193	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Santa Clara County	AARP Medicare Advantage SecureHorizons Focus (HMO)	Santa Clara County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	194	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Napa County	AARP Medicare Advantage SecureHorizons (HMO)	Napa County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	195	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Shasta and Tehama county	AARP Medicare Advantage SecureHorizons (HMO)	Shasta and Tehama county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	196	0	2021	01	AARP Medicare Advantage SecureHorizons Focus (HMO)	Stanislaus County	AARP Medicare Advantage SecureHorizons Focus (HMO)	Stanislaus County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	202	0	2021	01	UnitedHealthcare Medicare Advantage Assure (HMO)	Select counties in Northern California	UnitedHealthcare Medicare Advantage Assure (HMO)	Select counties in Northern California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	204	0	2021	01	AARP Medicare Advantage Walgreens (HMO)	San Diego County	AARP Medicare Advantage Walgreens (HMO)	San Diego County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	205	0	2021	01	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Marin County	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Marin County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	209	0	2021	01	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Santa Cruz County	UnitedHealthcare Canopy Health Medicare Advantage (HMO)	Santa Cruz County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	210	0	2021	02	AARP Medicare Advantage Freedom Plus (HMO-POS)	Los Angeles County		Los Angeles County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	214	0	2021	01	UnitedHealthcare Chronic Complete Focus (HMO C-SNP)	San Diego County		San Diego County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	215	0	2021	02	AARP Medicare Advantage Freedom Plus (HMO-POS)	Orange County	AARP Medicare Advantage Freedom Plus (HMO-POS)	Orange County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	216	0	2021	02	AARP Medicare Advantage Freedom Plus (HMO-POS)	Riverside and San Bernardino County		Riverside and San Bernardino County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0543	802	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CA Employer Sponsored Plan Service Area	MedicareComplete Retiree Plan (HMO)	CA Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CA Employer Sponsored Plan Service Area	MedicareComplete Retiree Plan (HMO)	CA Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0543	806	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CA Employer Sponsored Plan Service Area	MedicareComplete Retiree Plan (HMO)	CA Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0544	002	0	2021	01	Anthem MediBlue Value Plus (HMO)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	003	0	2021	01	Anthem MediBlue Connect (HMO D-SNP)	Los Angeles and Santa Clara counties		Los Angeles and Santa Clara counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	004	0	2021	01	Anthem MediBlue Diabetes Care (HMO C-SNP)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	005	0	2021	01	Anthem MediBlue Care On Site (HMO I-SNP)	Los Angeles, Orange, and San Bernardino counties		Los Angeles, Orange, and San Bernardino counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	007	0	2021	01	Anthem MediBlue StartSmart Plus (HMO)	Los Angeles, Orange, and San Bernardino Counties		Los Angeles, Orange, and San Bernardino Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	008	0	2021	01	Anthem MediBlue Value Plus (HMO)	San Bernardino County		San Bernardino County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	010	0	2021	01	Anthem MediBlue Diabetes Care (HMO C-SNP)	San Bernardino County		San Bernardino County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	013	0	2021	01	Anthem MediBlue Heart Care (HMO C-SNP)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	014	0	2021	01	Anthem MediBlue Lung Care (HMO C-SNP)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	015	0	2021	01	Anthem MediBlue ESRD Care (HMO C-SNP)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	019	0	2021	01	Anthem MediBlue Lung Care (HMO C-SNP)	San Bernardino County		San Bernardino County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	020	0	2021	01	Anthem MediBlue ESRD Care (HMO C-SNP)	San Bernardino County		San Bernardino County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	027	0	2021	01	Anthem MediBlue Value Plus (HMO)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	031	0	2021	01	Anthem MediBlue Lung (HMO C-SNP)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	032	0	2021	01	Anthem MediBlue Diabetes (HMO C-SNP)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	036	0	2021	01	Anthem MediBlue Heart (HMO C-SNP)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	038	0	2021	01	Anthem MediBlue Heart Care (HMO C-SNP)	San Bernardino County		San Bernardino County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	050	0	2021	01	Anthem MediBlue Care On Site (HMO I-SNP)	Santa Clara and Stanislaus Counties		Santa Clara and Stanislaus Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	052	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Fresno, Kings, Madera, and Tulare Counties		Fresno, Kings, Madera, and Tulare Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	053	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Kern County		Kern County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	054	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	San Francisco and Sacramento Counties		San Francisco and Sacramento Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	055	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Ventura County		Ventura County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	056	0	2021	01	Anthem MediBlue Plus (HMO)	Fresno, Kings, Madera and Tulare Counties		Fresno, Kings, Madera and Tulare Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	057	0	2021	01	Anthem MediBlue Plus (HMO)	San Francisco County		San Francisco County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	058	0	2021	01	Anthem MediBlue Select (HMO)	Los Angeles County		Los Angeles County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	059	0	2021	01	Anthem MediBlue Select (HMO)	Orange County		Orange County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	060	3	2021	01	Anthem MediBlue Plus (HMO)	Select County in Inland Empire		San Bernardino County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	060	4	2021	01	Anthem MediBlue Plus (HMO)	Select County in Inland Empire		Riverside County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	061	0	2021	01	Anthem MediBlue Plus (HMO)	Orange and Los Angeles Counties		Orange and Los Angeles Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	062	0	2021	01	Anthem MediBlue Plus (HMO)	Kern County		Kern County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	063	0	2021	01	Anthem MediBlue Plus (HMO)	Ventura County		Ventura County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	064	0	2021	01	Anthem MediBlue Plus (HMO)	Sacramento County		Sacramento County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	065	0	2021	01	Anthem MediBlue Plus (HMO)	San Diego County		San Diego County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	066	0	2021	01	Anthem MediBlue Select (HMO)	San Bernardino County		San Bernardino County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	067	0	2021	01	Anthem MediBlue Select (HMO)	Riverside County		Riverside County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	069	0	2021	01	Anthem MediBlue Select (HMO)	San Francisco County		San Francisco County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	070	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	San Diego County		San Diego County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	071	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	Riverside and San Bernardino Counties		Riverside and San Bernardino Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	072	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	074	0	2021	01	Anthem MediBlue Plus (HMO)	Yolo County		Yolo County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	081	0	2021	01	Anthem MediBlue Extra (HMO)	Counties: LA, Orange, San Bern., Riv, San Diego		Counties: LA, Orange, San Bern., Riv, San Diego	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	087	0	2021	01	Anthem MediBlue Dual Plus (HMO D-SNP)	Fresno, Kings, Madera, and Tulare Counties		Fresno, Kings, Madera, and Tulare Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	088	0	2021	01	Anthem MediBlue Dual Plus (HMO D-SNP)	Kern County		Kern County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	089	0	2021	01	Anthem MediBlue Dual Plus (HMO D-SNP)	San Francisco and Sacramento Counties		San Francisco and Sacramento Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	090	0	2021	01	Anthem MediBlue Dual Plus (HMO D-SNP)	Ventura County		Ventura County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	091	0	2021	01	Anthem MediBlue Select (HMO)	San Diego County		San Diego County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	093	0	2021	01	Anthem MediBlue Care To You (HMO I-SNP)	Sacramento County		Sacramento County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	094	0	2021	01	Anthem MediBlue Diabetes Care Plus (HMO C-SNP)	Sacramento County		Sacramento County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	095	0	2021	01	Anthem MediBlue Plus (HMO)	San Joaquin County		San Joaquin County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	096	0	2021	01	Anthem MediBlue Plus (HMO)	San Mateo County		San Mateo County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	097	0	2021	01	Anthem MediBlue Plus (HMO)	Alameda County		Alameda County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	098	0	2021	01	Anthem MediBlue Select (HMO)	Alameda County		Alameda County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	099	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	Alameda and San Mateo Counties		Alameda and San Mateo Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	100	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	San Joaquin County		San Joaquin County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	101	0	2021	01	Anthem MediBlue Lung Care (HMO C-SNP)	Santa Clara County		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	102	0	2021	01	Anthem MediBlue Diabetes Care (HMO C-SNP)	Santa Clara County		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	103	0	2021	01	Anthem MediBlue Lung Care (HMO C-SNP)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	104	0	2021	01	Anthem MediBlue Diabetes Care (HMO C-SNP)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	105	0	2021	01	Anthem MediBlue Heart Care (HMO C-SNP)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	106	0	2021	01	Anthem MediBlue Heart Care (HMO C-SNP)	Santa Clara County		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	107	0	2021	01	Anthem MediBlue Value (HMO)	Stanislaus County		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	108	0	2021	01	Anthem MediBlue Plus (HMO)	Santa Clara County		Santa Clara County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	110	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	Santa Clara County		Santa Clara County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	117	1	2021	01	Anthem MediBlue Lung (HMO C-SNP)	Santa Clara and San Benito Counties		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	117	2	2021	01	Anthem MediBlue Lung (HMO C-SNP)	Santa Clara and San Benito Counties		San Benito County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	118	1	2021	01	Anthem MediBlue Diabetes (HMO C-SNP)	Santa Clara and San Benito Counties		San Benito County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				9000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	118	2	2021	01	Anthem MediBlue Diabetes (HMO C-SNP)	Santa Clara and San Benito Counties		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				9000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	119	1	2021	01	Anthem MediBlue Heart (HMO C-SNP)	Santa Clara and San Benito Counties		San Benito County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	119	2	2021	01	Anthem MediBlue Heart (HMO C-SNP)	Santa Clara and San Benito Counties		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	120	1	2021	01	Anthem MediBlue Value Plus (HMO)	Santa Clara and San Benito Counties		San Benito County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	120	2	2021	01	Anthem MediBlue Value Plus (HMO)	Santa Clara and San Benito Counties		Santa Clara County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	121	1	2021	01	Anthem MediBlue StartSmart Plus (HMO)	Select counties in California		San Benito County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	121	2	2021	01	Anthem MediBlue StartSmart Plus (HMO)	Select counties in California		Santa Clara and Stanislaus Counties	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	122	1	2021	01	Anthem MediBlue Connect Plus (HMO)	Select counties in California		Select counties in California	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	122	2	2021	01	Anthem MediBlue Connect Plus (HMO)	Select counties in California		San Benito County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	122	3	2021	01	Anthem MediBlue Connect Plus (HMO)	Select counties in California		Stanislaus County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H0544	801	0	2021	01	Anthem EGWP (HMO)	California		California	1	3	1	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	802	0	2021	01	Anthem EGWP MAPD (HMO)	California		California	1	3	1	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	804	0	2021	01	Anthem EGWP MAPD (HMO)	California		California	1	3	1	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	805	0	2021	01	Senior Secure (HMO)	California, select counties		California, select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	806	0	2021	01	Senior Secure (HMO)	California, select counties		California, select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	807	0	2021	01	Senior Secure (HMO)	California, select counties		California, select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	808	0	2021	01	Senior Secure (HMO)	Select counties in California		Select counties in California	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	809	0	2021	01	Senior Secure (HMO)	Select CA counties		Select CA counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	810	0	2021	01	Senior Secure (HMO)	Select CA Counties		Select CA Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	811	0	2021	01	Senior Secure (HMO)	Select CA Counties		Select CA Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0544	812	0	2021	01	Senior Secure (HMO)	Select CA counties		Select CA counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												5000000000208002100308002100408002100508002100608002100000000000	5000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ca/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare	www.anthem.com/ca/medicare
H0545	001	0	2021	01	Inter Valley Health Plan Service To Seniors (HMO)	Counties: LA, RV, OC and SB	Inter Valley Health Plan Service To Seniors (HMO)	Counties: LA, RV, OC and SB	1	0	0	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	MemberServices@ivhp.com	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	Pharmacyteam@ivhp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ivhp.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	http://www.ivhp.com	http://www.ivhp.com	www.ivhp.com
H0545	012	0	2021	01	Inter Valley Health Plan Desert Preferred Choice (HMO)	Riverside County	Inter Valley Health Plan Desert Preferred Choice (HMO)	Riverside County	1	0	0	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	MemberServices@ivhp.com	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	Pharmacyteam@ivhp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ivhp.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	http://www.ivhp.com	http://www.ivhp.com	www.ivhp.com
H0545	015	0	2021	01	Inter Valley Health Plan Vitality Plus (HMO)	LA, San Bernardino, Riverside and Orange Counties	Inter Valley Health Plan Vitality Plus (HMO)	LA, San Bernardino, Riverside and Orange Counties	1	0	0	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	MemberServices@ivhp.com	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	Pharmacyteam@ivhp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.ivhp.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	http://www.ivhp.com	http://www.ivhp.com	www.ivhp.com
H0545	801	0	2021	01	Inter Valley Health Plan Active Plus I (HMO)	Counties: LA, OC, RV SB	Inter Valley Health Plan Active Plus I (HMO)	Counties: LA, OC, RV SB	1	3	1	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	MemberServices@ivhp.com	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	Pharmacyteam@ivhp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ivhp.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	http://www.ivhp.com	http://www.ivhp.com	www.ivhp.com
H0545	802	0	2021	01	Inter Valley Health Plan Active Plus II (HMO)	Counties: LA, OC, RV SB	Inter Valley Health Plan Active Plus II (HMO)	Counties: LA, OC, RV SB	1	3	1	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	MemberServices@ivhp.com	300 S Park Avenue	PO Box 6002	Pomona	CA	91769		info@ivhp.com	Pharmacyteam@ivhp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ivhp.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	http://www.ivhp.com	http://www.ivhp.com	www.ivhp.com
H0562	009	0	2021	01	Health Net Healthy Heart (HMO)	San Francisco County	Health Net Healthy Heart (HMO)	San Francisco County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor
H0562	012	0	2021	01	Health Net Healthy Heart (HMO)	San Diego County	Health Net Healthy Heart (HMO)	San Diego County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	039	0	2021	01	Health Net Healthy Heart (HMO)	Yolo county	Health Net Healthy Heart (HMO)	Yolo county	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/find-doctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	044	0	2021	01	Health Net Green (HMO)	L.A., Riverside, S.Bern., Ala, Pla, Sac, Sta	Health Net Green (HMO)	L.A., Riverside, S.Bern., Ala, Pla, Sac, Sta	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	055	0	2021	01	Health Net Amber I (HMO D-SNP)	L.A., Kern, Org, Riv, SB, Fresno, SD, SF, Tulare	Health Net Amber I (HMO D-SNP)	L.A., Kern, Org, Riv, SB, Fresno, SD, SF, Tulare	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	068	0	2021	01	Health Net Healthy Heart (HMO)	Alameda and Stanislaus Counties	Health Net Healthy Heart (HMO)	Alameda and Stanislaus Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	079	0	2021	01	Health Net Ruby (HMO)	Kern County	Health Net Ruby (HMO)	Kern County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	084	0	2021	01	Health Net Healthy Heart (HMO)	Placer, Sacramento Counties	Health Net Healthy Heart (HMO)	Placer, Sacramento Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	090	0	2021	01	Health Net Healthy Heart (HMO)	Fresno County	Health Net Healthy Heart (HMO)	Fresno County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	092	0	2021	01	Health Net Jade (HMO C-SNP)	Kern, L. A. and Orange Counties	Health Net Jade (HMO C-SNP)	Kern, L. A. and Orange Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	1	4	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	097	0	2021	01	Health Net Ruby Select (HMO)	San Francisco	Health Net Ruby Select (HMO)	San Francisco	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	103	0	2021	01	Health Net Ruby Select (HMO)	Yolo County	Health Net Ruby Select (HMO)	Yolo County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	112	0	2021	01	Health Net Ruby Select (HMO)	Fresno County	Health Net Ruby Select (HMO)	Fresno County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	113	0	2021	01	Health Net Ruby Select (HMO)	Alameda County	Health Net Ruby Select (HMO)	Alameda County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	114	0	2021	01	Health Net Jade (HMO C-SNP)	San Diego	Health Net Jade (HMO C-SNP)	San Diego	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	118	0	2021	01	Health Net Jade (HMO C-SNP)	Fresno and San Francisco County	Health Net Jade (HMO C-SNP)	Fresno and San Francisco County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	119	0	2021	01	Health Net Healthy Heart (HMO)	Imperial County	Health Net Healthy Heart (HMO)	Imperial County	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	120	0	2021	01	Health Net Ruby (HMO)	Santa Clara and Stanislaus Counties	Health Net Ruby (HMO)	Santa Clara and Stanislaus Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	121	0	2021	01	Health Net Amber II (HMO D-SNP)	Parts of Southern and Northern California	Health Net Amber II (HMO D-SNP)	Parts of Southern and Northern California	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	122	0	2021	01	Health Net Sapphire (HMO)	Parts of Southern and Northern California	Health Net Sapphire (HMO)	Parts of Southern and Northern California	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	123	0	2021	01	Health Net Healthy Heart (HMO)	LA, Orange, Riverside and San Bernardino Counties	Health Net Healthy Heart (HMO)	LA, Orange, Riverside and San Bernardino Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	124	0	2021	01	Health Net Ruby Select (HMO)	Sacramento and Placer Counties	Health Net Ruby Select (HMO)	Sacramento and Placer Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	125	0	2021	01	Health Net Gold Select (HMO)	Los Angeles and Orange Counties	Health Net Gold Select (HMO)	Los Angeles and Orange Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	126	0	2021	01	Health Net Gold Select (HMO)	Riverside and San Bernardino Counties	Health Net Gold Select (HMO)	Riverside and San Bernardino Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	801	0	2021	01	Health Net Seniority Plus Employer (HMO)	California	Health Net Seniority Plus Employer (HMO)	California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthnet.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	803	0	2021	01	Health Net Seniority Plus Employer (HMO)	California	Health Net Seniority Plus Employer (HMO)	California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthnet.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0562	804	0	2021	01	Health Net Seniority Plus Employer (HMO)	California	Health Net Seniority Plus Employer (HMO)	California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthnet.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H0571	001	0	2021	01	CCHP Senior Program (HMO)	San Francisco and San Mateo Counties		San Francisco and San Mateo Counties	1	0	0	445 Grant Avenue	Suite 700	San Francisco	CA	94108		sales@cchphealthplan.com	memberservices@cchphealthplan.com	445 Grant Avenue	Suite 700	San Francisco	CA	94108		sales@cchphealthplan.com	memberservices@cchphealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cchphealthplan.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0		www.cchphealthplan.com/medicare-rx-benefit-information-including-part-d	www.cchphealthplan.com/medicare-rx-benefit-information-including-part-d
H0571	005	0	2021	01	CCHP Senior Select Program (HMO D-SNP)	San Francisco County		San Francisco County	1	0	0	445 Grant Avenue	Suite 700	San Francisco	CA	94108		sales@cchphealthplan.com	memberservices@cchphealthplan.com	445 Grant Avenue	Suite 700	San Francisco	CA	94108		sales@cchphealthplan.com	memberservices@cchphealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cchphealthplan.com/medicare	1	3	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cchphealthplan.com/medicare-rx-benefit-information-including-part-d	www.cchphealthplan.com/medicare-rx-benefit-information-including-part-d
H0571	007	0	2021	01	CCHP Senior Value Program (HMO)	San Francisco and San Mateo Counties		San Francisco and San Mateo Counties	1	0	0	445 Grant Avenue	Suite 700	San Francisco	CA	94108		sales@cchphealthplan.com	memberservices@cchphealthplan.com	445 Grant Avenue	Suite 700	San Francisco	CA	94108		sales@cchphealthplan.com	memberservices@cchphealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cchphealthplan.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://cchphealthplan.com/find-a-provider	https://cchphealthplan.com/medicare-member/	https://cchphealthplan.com/medicare-rx
H0609	007	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Denver Metro area		Denver Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	012	0	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Denver Metro area		Denver Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	018	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Denver Metro area		Denver Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	025	0	2021	01	AARP Medicare Advantage (HMO)	Pima County		Pima County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	026	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Maricopa and Pinal Counties		Maricopa and Pinal Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	027	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Maricopa County		Maricopa County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	028	0	2021	01	AARP Medicare Advantage (HMO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	031	0	2021	01	AARP Medicare Advantage Premier (HMO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	032	0	2021	01	UnitedHealthcare Medicare Advantage Focus (HMO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	033	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Lyon and Washoe counties		Lyon and Washoe counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	034	1	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Select Counties in Colorado		Larimer and Weld counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	034	2	2021	01	AARP Medicare Advantage SecureHorizons Plan 1 (HMO)	Select Counties in Colorado		El Paso, Fremont, Pueblo, and Teller counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	036	1	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Colorado Springs Metro Area		Larimer and Weld counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	036	2	2021	01	AARP Medicare Advantage SecureHorizons Plan 2 (HMO)	Colorado Springs Metro Area		El Paso, Fremont, Pueblo, and Teller counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	037	0	2021	01	UnitedHealthcare Medicare Advantage Assist (HMO C-SNP)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	038	0	2021	01	AARP Medicare Advantage Walgreens Plan 1 (HMO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	040	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Lyon and Washoe counties		Lyon and Washoe counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	041	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select Counties in CO Area		Select Counties in CO Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0609	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	806	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	CO Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	807	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	808	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	809	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	810	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	811	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Clark and Nye counties		Clark and Nye counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	812	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Clark and Nye counties		Clark and Nye counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	813	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NV Employer Sponsored Plan Service Area		NV Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	814	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NV Employer Sponsored Plan Service Area		NV Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	815	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NV Employer Sponsored Plan Service Area		NV Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	816	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NV Employer Sponsored Plan Service Area		NV Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com	P.O. Box 30770		Salt Lake City	UT	84130			UHCNV-Member-HPN@uhc.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	817	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	818	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	AZ		AZ	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	819	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	AZ		AZ	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	820	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	AZ		AZ	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0609	821	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	AZ		AZ	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0613	001	0	2021	20	Total Longterm Care - Dual eligibles (PACE)	Metro Denver,Pueblo,Loveland,Fort Collins,Greeley		Metro Denver,Pueblo,Loveland,Fort Collins,Greeley	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	4000000000208001630308001630408001630508001630608001615000000000	4000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		http://www.granerx.com	http://www.totallongtermcare.org
H0613	003	0	2021	20	Total Longterm Care - Medicare only (PACE)	Metro Denver,Pueblo,Loveland,Fort Collins,Greeley		Metro Denver,Pueblo,Loveland,Fort Collins,Greeley	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	4000000000208001630308001630408001630508001630608001630000000000	4000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		http://www.granerx.com	http://www.totallongtermcare.org
H0624	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Denver and Colorado Springs metro areas		Denver and Colorado Springs metro areas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H0628	001	0	2021	01	Aetna Medicare Premier (HMO)	Toledo Area		Toledo Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	003	0	2021	01	Aetna Medicare Premier (HMO)	Dayton and Cincinnati OH		Dayton and Cincinnati OH	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	005	0	2021	01	Aetna Medicare Premier (HMO)	Greater Cleveland Area		Greater Cleveland Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	006	0	2021	01	Aetna Medicare Premier (HMO)	Northern Kentucky		Northern Kentucky	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	007	0	2021	01	Aetna Medicare Premier (HMO)	Bowling Green and Southwest Kentucky Area		Bowling Green and Southwest Kentucky Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	008	0	2021	01	Aetna Medicare Premier (HMO)	Lexington Area		Lexington Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	009	0	2021	01	Aetna Medicare Premier (HMO)	Louisville Area		Louisville Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	010	0	2021	01	Aetna Medicare Premier (HMO)	Ashland Area		Ashland Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	011	0	2021	01	Aetna Medicare Premier (HMO)	Eastern Kentucky Area		Eastern Kentucky Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	012	0	2021	01	Aetna Medicare Assure 1 (HMO D-SNP)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	013	0	2021	01	Aetna Medicare Assure 1 (HMO D-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	014	0	2021	01	Aetna Medicare Eagle (HMO)	Louisville Area		Louisville Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	015	0	2021	01	Aetna Medicare Eagle (HMO)	Central Ohio & Cleveland Area		Central Ohio & Cleveland Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	016	0	2021	01	Aetna Medicare Eagle (HMO)	Cincinnati Area		Cincinnati Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	017	0	2021	01	Aetna Medicare Premier (HMO)	Greater Central Ohio Area		Greater Central Ohio Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	801	0	2021	01	Aetna Medicare Plan (HMO)	Ohio		Ohio	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0628	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Ohio		Ohio	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H0630	013	0	2021	01	Kaiser Permanente Senior Advantage Core (HMO)	Denver Metro Area		Denver Metro Area	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	014	0	2021	01	Senior Advantage Medicare Medicaid (HMO D-SNP)	Denver Metro Area		Denver Metro Area	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	015	0	2021	01	Kaiser Permanente Senior Advantage Silver (HMO)	Denver Metro Area		Denver Metro Area	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	016	0	2021	01	Kaiser Permanente Senior Advantage Gold (HMO)	Denver Metro Area		Denver Metro Area	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	017	0	2021	01	Kaiser Permanente Senior Advantage Core (HMO)	Southern Colorado		Southern Colorado	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	020	0	2021	01	Kaiser Permanente Senior Advantage Core (HMO)	Northern Colorado		Northern Colorado	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	021	0	2021	01	Kaiser Permanente Senior Advantage Silver (HMO)	Northern Colorado		Northern Colorado	1	0	0	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	023	0	2021	01	Kaiser Permanente Senior Advantage Enhanced (HMO)	Southern Colorado		Southern Colorado	1	0	0	2500 S Havana St.		Aurora	CO	80014				2500 S Havana St.		Aurora	CO	80014				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	805	0	2021	01	Senior Advantage Group MA-PD_Part B only (HMO)	Denver Metro Area		Denver Metro Area	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	806	0	2021	01	Senior Advantage Group MA only_Part B only (HMO)	Denver Metro Area		Denver Metro Area	1	3	1	2500 S. Havana St.		Aurora	CO	80014												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	807	0	2021	01	Senior Advantage Group MA-PD (HMO)	Denver Metro Area		Denver Metro Area	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	808	0	2021	01	Senior Adv_Group_MA only (HMO)	Denver Metro Area		Denver Metro Area	1	3	1	2500 S. Havana St.		Aurora	CO	80014												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	809	0	2021	01	FEHB B only with D (HMO)	Denver Metro Area		Denver Metro Area	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	810	0	2021	01	FEHB AB with D (HMO)	Denver Metro Area		Denver Metro Area	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	811	0	2021	01	Senior Advantage Group MA-PD_Part B only (HMO)	Southern Colorado		Southern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	812	0	2021	01	Senior Advantage Group MA only_Part B only (HMO)	Southern Colorado		Southern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	813	0	2021	01	Senior Advantage Group MA-PD (HMO)	Southern Colorado		Southern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	814	0	2021	01	Senior Adv Group_MA only (HMO)	Southern Colorado		Southern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	815	0	2021	01	FEHB B only with D (HMO)	Southern Colorado		Southern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	816	0	2021	01	FEHB AB with D (HMO)	Southern Colorado		Southern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	817	0	2021	01	Senior Advantage Group MAPD Part B Only (HMO)	Northern Colorado		Northern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	818	0	2021	01	Senior Advantage Group MA Only Part B Only (HMO)	Northern Colorado		Northern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	819	0	2021	01	Senior Advantage Group MAPD (HMO)	Northern Colorado		Northern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	820	0	2021	01	Senior Advantage Group MA Only (HMO)	Northern Colorado		Northern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	821	0	2021	01	FEHB B Only with D (HMO)	Northern Colorado		Northern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0630	822	0	2021	01	FEHB AB with D (HMO)	Northern Colorado		Northern Colorado	1	3	1	2500 S. Havana St.		Aurora	CO	80014				2500 S. Havana St.		Aurora	CO	80014				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H0657	005	0	2021	18	Friday Health Plans Silver SV Plan (Cost)	The 6 County San Luis Valley Area	Friday Health Plans Plata SV Plan (Cost)	The 6 County San Luis Valley Area	1	0	0	700 Main Street #100		Alamosa	CO	81101		dpottberg@cochoice.com	dessa.pottberg@fridayhealthplans.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fridayhealthplans.com	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.fridayhealthplans.com		
H0657	006	0	2021	18	Friday Health Plans Gold SV Plan (Cost)	The 6 County San Luis Valley Area	Friday Health Plans Oro SV Plan (Cost)	The 6 County San Luis Valley Area	1	0	0	700 Main Street #100		Alamosa	CO	81101		dpottberg@cochoice.com	dessa.pottberg@fridayhealthplans.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fridayhealthplans.com	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.fridayhealthplans.com		
H0657	008	0	2021	18	Friday Health Plans Silver Plan (Cost)	BEN, CHA, CRO, CUS, FRE, HUE, LAS, OTE, PRO, YUM	Friday Health Plans Plata Plan (Cost)	BEN, CHA, CRO, CUS, FRE, HUE, LAS, OTE, PRO, YUM	1	0	0	700 Main Street #100		Alamosa	CO	81101		dpottberg@cochoice.com	dessa.pottberg@fridayhealthplans.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fridayhealthplans.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.fridayhealthplans.com		
H0657	009	0	2021	18	Friday Health Plans Gold Plan (Cost)	Colorado Counties other than San Luis Valley	Friday Health Plans Oro Plan (Cost)	Colorado Counties other than San Luis Valley	1	0	0	700 Main Street #100		Alamosa	CO	81101		dpottberg@cochoice.com	dessa.pottberg@fridayhealthplans.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fridayhealthplans.com	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.fridayhealthplans.com		
H0672	001	0	2021	01	Cigna Preferred Medicare (HMO)	Denver Area	Cigna Preferred Medicare (HMO)	Denver Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0672	002	0	2021	01	Cigna Preferred Medicare (HMO)	Boulder Area	Cigna Preferred Medicare (HMO)	Boulder Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0672	003	0	2021	01	Cigna Preferred Medicare (HMO)	Fort Collins Area	Cigna Preferred Medicare (HMO)	Fort Collins Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0672	004	0	2021	01	Cigna Preferred Medicare (HMO)	Colorado Springs Area	Cigna Preferred Medicare (HMO)	Colorado Springs Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0672	005	0	2021	01	Cigna Preferred Medicare (HMO)	Albuquerque Area	Cigna Preferred Medicare (HMO)	Albuquerque Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0672	006	0	2021	01	Cigna Preferred Medicare (HMO)	Ohio	Cigna Preferred Medicare (HMO)	Ohio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0672	801	0	2021	01	Cigna Preferred Medicare (HMO)	Colorado & New Mexico	Cigna Preferred Medicare (HMO)	Colorado & New Mexico	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H0710	004	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in AL, FL, MS and TN		Select Counties in AL, FL, MS and TN	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	005	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Maricopa, Pima, Pinal, and Yavapai counties		Maricopa, Pima, Pinal, and Yavapai counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	007	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Colorado		Select Counties in Colorado	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	008	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in Colorado		Select Counties in Colorado	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	009	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Fairfield, Hartford, and New Haven counties		Fairfield, Hartford, and New Haven counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	010	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	012	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	013	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	015	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Maine and New Hampshire		Select Counties in Maine and New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	016	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	017	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Select Counties in Pennsylvania, State of Delaware		Select Counties in Pennsylvania, State of Delaware	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	020	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select counties in Texas		Select counties in Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	026	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Connecticut and New Jersey		Select Counties in Connecticut and New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	027	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	030	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select counties in Washington		Select counties in Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	031	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select counties in Washington and Idaho		Select counties in Washington and Idaho	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	032	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Select Counties in Maryland and Virginia		Select Counties in Maryland and Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	033	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	034	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	035	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	036	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Select Counties in Oregon		Select Counties in Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	037	0	2021	04	UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)	Select Counties in Oregon		Select Counties in Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	038	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Hillsborough County		Hillsborough County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	039	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Chicago Metro area		Chicago Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	041	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Twin Cities Metro Area		Select Counties in Twin Cities Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	042	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	043	0	2021	04	UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	046	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Iowa		Select Counties in Iowa	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	047	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	049	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in New Hampshire		Select Counties in New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	050	0	2021	04	UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)	Select Counties in Rhode Island		Select Counties in Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	051	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	052	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in OK		Select Counties in OK	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	053	0	2021	04	UnitedHealthcare Nursing Home Plan (PPO I-SNP)	Select Counties in SC		Select Counties in SC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	801	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	802	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	803	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	804	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	805	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	806	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	807	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	808	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	809	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	810	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	811	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	812	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	813	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	814	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	815	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	816	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	817	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	818	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	819	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	820	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	821	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	822	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	823	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	824	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	825	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	826	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	827	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	829	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	830	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0710	831	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0712	005	0	2021	01	WellCare Access (HMO D-SNP)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0712	019	0	2021	01	WellCare Value (HMO)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0712	020	0	2021	01	WellCare Compass (HMO)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0712	022	0	2021	01	WellCare Value (HMO)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0712	023	0	2021	01	WellCare Value (HMO)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0712	025	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0712	029	0	2021	01	WellCare Freedom (HMO D-SNP)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0724	001	0	2021	01	Allwell Medicare (HMO)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0724	005	0	2021	01	Allwell Medicare Essentials (HMO)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0724	006	0	2021	01	Allwell Medicare Complement (HMO)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0724	007	0	2021	01	Allwell Medicare Boost (HMO)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0724	801	0	2021	01	Allwell Group (HMO)	Countywide		Countywide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0724	802	0	2021	01	Allwell Group (HMO)	Countywide		Countywide	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0724	803	0	2021	01	Allwell Group (HMO)	Countywide		Countywide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0755	030	0	2021	01	UnitedHealthcare Medicare Advantage Plan 1 (HMO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	031	0	2021	01	UnitedHealthcare Medicare Advantage Plan 2 (HMO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	032	0	2021	01	UnitedHealthcare Medicare Advantage Patriot (HMO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	033	0	2021	01	UnitedHealthcare Medicare Advantage Plan 3 (HMO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	037	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select counties in New Jersey		Select counties in New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	038	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Essex and Ocean Counties		Essex and Ocean Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	040	1	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	040	2	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select Counties in New Jersey		Burlington, Hunterdon, and Mercer Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	041	1	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Select counties in New Jersey		Select Counties in New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	041	2	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Select counties in New Jersey		Burlington, Hunterdon, and Mercer Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	042	1	2021	01	AARP Medicare Advantage Plan 4 (HMO)	Select counties in New Jersey		Select Counties in New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	042	2	2021	01	AARP Medicare Advantage Plan 4 (HMO)	Select counties in New Jersey		Burlington, Hunterdon, and Mercer Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H0755	810	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Connecticut		Connecticut	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	811	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Connecticut		Connecticut	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	610097	9999	www.UHCMedicareSolutions.com
H0755	812	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Connecticut		Connecticut	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	813	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NJ		NJ	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCRetiree.com	www.UHCRetiree.com	www.UHCRetiree.com
H0755	814	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NJ		NJ	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0755	815	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	NJ		NJ	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H0783	001	0	2021	01	Humana Gold Plus SNP-DE H0783-001 (HMO D-SNP)	Cameron, Hidalgo and Willacy counties		Cameron, Hidalgo and Willacy counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H0798	001	0	2021	01	Medica Advantage Solution with CHI Health (HMO)	Select counties in IA and NE		Select counties in IA and NE	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H0809	001	0	2021	20	Mercy LIFE, Inc. (PACE)	Mercy LIFE		Mercy LIFE	1	3	0									200 Hillside Circle	Suite 1	West Springfield	MA	01089		rae.selinger@trinity-health.org	rae.selinger@trinity-health.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mymercylife.com	0	0	1			0					3	0	0		pharmastar.com	www.mercycares.com
H0809	002	0	2021	20	Mercy LIFE, Inc. (PACE)	Mercy LIFE		Mercy LIFE	1	3	0									200 Hillside Circle	Suite 1	West Springfield	MA	01089		rae.selinger@trinity-health.org	rae.selinger@trinity-health.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mymercylife.com	0	0	1			0					3	0	0		pharmastar.com	www.mercycares.com
H0819	001	0	2021	20	Senior LIFE York & Harrisburg Dual Eligibile (PACE)	York & Harrisburg County		York & Harrisburg County	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	www.seniorlifeyork.com
H0819	002	0	2021	20	Senior LIFE York & Harrisburg Medicare Only (PACE)	York & Harrisburg County		York & Harrisburg County	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.seniorlifeyork.com	0	0	1			0					3	0	0		http://granerx.com/	www.seniorlifeyork.com
H0838	020	0	2021	01	Brand New Day Harmony Choice Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Harmony Choice Plan (HMO C-SNP)	All Brand New Day Approved Counties	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	024	0	2021	01	Brand New Day Dual Access Plan (HMO D-SNP)	FRE IMP KER KIN LA MAD ORG RIV SAC SBD SF SJ TUL	Brand New Day Dual Access Plan (HMO D-SNP)	FRE IMP KER KIN LA MAD ORG RIV SAC SBD SF SJ TUL	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	025	0	2021	01	Brand New Day Classic Care I Plan (HMO)	Counties:  KER LA ORA RIV SBD SD	Brand New Day Classic Care I Plan (HMO)	Counties:  KER LA ORA RIV SBD SD	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	028	0	2021	01	Brand New Day Bridges Care Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Bridges Care Plan (HMO C-SNP)	All Brand New Day Approved Counties	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	029	0	2021	01	Brand New Day Bridges Choice Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Bridges Choice Plan (HMO C-SNP)	All Brand New Day Approved Counties	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	032	0	2021	01	Brand New Day Harmony Care Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Harmony Care Plan (HMO C-SNP)	All Brand New Day Approved Counties	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	033	0	2021	01	Brand New Day Classic Choice Plan (HMO)	All Brand New Day Approved Counties	Brand New Day Classic Choice Plan (HMO)	All Brand New Day Approved Counties	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	037	0	2021	01	Brand New Day Classic Care II Plan (HMO)	All Brand New Day Approved Counties	Brand New Day Classic Care II Plan (HMO)	All Brand New Day Approved Counties	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	039	1	2021	01	Brand New Day Embrace Care Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Embrace Care Plan (HMO C-SNP)	KER LA ORA RIV SBD SD	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	039	2	2021	01	Brand New Day Embrace Care Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Embrace Care Plan (HMO C-SNP)	FRE IMP KIN MAD SAC SF SJ SM SCL TUL	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	040	1	2021	01	Brand New Day Embrace Choice Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Embrace Choice Plan (HMO C-SNP)	KER LA ORA RIV SBD SD	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	040	2	2021	01	Brand New Day Embrace Choice Plan (HMO C-SNP)	All Brand New Day Approved Counties	Brand New Day Embrace Choice Plan (HMO C-SNP)	FRE IMP KIN SAC SF SJ SM SCL TUL MAD	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	042	0	2021	01	Brand New Day Select Care I Plan (HMO I-SNP)	Counties: LA, ORA, RIV, SBD	Brand New Day Select Care I Plan (HMO I-SNP)	Counties: LA, ORA, RIV, SBD	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	043	0	2021	01	Brand New Day Select Care II Plan (HMO I-SNP)	FRE IMP KER KIN MAD SAC SD SF SJ SM SCL TUL	Brand New Day Select Care II Plan (HMO I-SNP)	FRE IMP KER KIN MAD SAC SD SF SJ SM SCL TUL	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	044	0	2021	01	Brand New Day Select Choice I Plan (HMO I-SNP)	LA ORA SBD RIV	Brand New Day Select Choice I Plan (HMO I-SNP)	LA ORA SBD RIV	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0838	045	0	2021	01	Brand New Day Select Choice II Plan (HMO I-SNP)	KER SD FRE IMP KIN SM SCL MAD SAC SF SJ TUL	Brand New Day Select Choice II Plan (HMO I-SNP)	KER SD FRE IMP KIN SM SCL MAD SAC SF SJ TUL	1	0	0	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5455 Garden Grove Blvd	Suite 500	Westminster	CA	92683		compliance@universalcare.com	compliance@universalcare.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bndhmo.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bndhmo.com	www.bndhmo.com	www.bndhmo.com
H0839	001	0	2021	20	Senior CommUnity Care of North Carolina (PACE)	Wake Co, Durham Co, Granville Co.		Wake Co, Durham Co, Granville Co.	1	3	0									4022 Stirrup Creek Drive	Suite 315	Durham	NC	27703				2100001200200001200300001200400001200500001200600001200700001200	2100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorcommunitycarenc.org	0	0	1			0					3	0	0		www.seniorcommunitycarenc.org	www.seniorcommunitycarenc.org
H0839	002	0	2021	20	Senior CommUnity Care of North Carolina (PACE)	Wake Co., Durham Co, Granville Co		Wake Co., Durham Co, Granville Co	1	3	0									4022 Stirrup Creek Drive	Suite 315	Durham	NC	27703				2100001200200001200300001200400001200500001200600001200700001200	2100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorcommunitycarenc.org	0	0	1			0					3	0	0		www.seniorcommunitycarenc.org	www.seniorcommunitycarenc.org
H0885	001	0	2021	04	Braven Medicare Choice (PPO)	Eastern New Jersey		Eastern New Jersey	1	0	0	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H0885	002	0	2021	04	Braven Medicare Freedom (PPO)	Eastern New Jersey		Eastern New Jersey	1	0	0	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H0885	801	0	2021	04	Braven Medicare Group (PPO)	National		National	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H0885	802	0	2021	04	Braven Medicare Group w/Rx (PPO)	National		National	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H0885	803	0	2021	04	Braven Medicare Group w/Rx Ideal (PPO)	National		National	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H0885	804	0	2021	04	Braven Medicare Group w/Rx Complete (PPO)	National		National	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H0907	001	0	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Iowa		Select Counties in Iowa	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H0908	001	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Statewide		Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	advantage.buckeyehealthplan.com/findadoctor	advantage.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0908	801	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0908	802	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	2	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0908	803	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.buckeyehealthplan.com	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/findadoctor	allwell.buckeyehealthplan.com/formulary
H0913	002	0	2021	02	WellCare Value (HMO-POS)	Select counties in NJ		Select counties in NJ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0913	013	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in NJ		Select counties in NJ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0913	015	0	2021	01	WellCare Compass (HMO)	Select counties in NJ		Select counties in NJ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0913	017	0	2021	01	WellCare Focus (HMO)	Select counties in NJ		Select counties in NJ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0927	001	0	2021	48	Blue Cross Community MMAI (Medicare-Medicaid Plan)	State of IL		State of IL	1	0	0	PO Box 3836		Scranton	PA	18505				PO Box 3836		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.bcbsil.com/mmai	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0		www.myprime.com/v/BCBSIL/MEDICARE_D/ILBCCMAI/en/find-pharmacy.html	www.bcbsil.com/mmai/plan_details/drug_coverage.html
H0934	001	0	2021	20	Pacific PACE (PACE)	Parts of Los Angeles County		Parts of Los Angeles County	1	3	0									50 Alessandro Place, Suite A20		Pasadena	CA	91105				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://pacificpace.welbehealth.com	0	0	1			0					3	0	0		www.omnicare.com	NA
H0934	002	0	2021	20	Pacific PACE (PACE)	Parts of Los Angeles County		Parts of Los Angeles County	1	3	0									50 Alessandro Place, Suite A20		Pasadena	CA	91105				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://pacificpace.welbehealth.com	0	0	1			0					3	0	0		www.omnicare.com	NA
H0969	001	0	2021	04	WellCare Premier (PPO)	Select counties in NH		Select counties in NH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0969	002	0	2021	04	WellCare Prime (PPO)	Select counties in NH		Select counties in NH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H0982	001	0	2021	01	SOLIS SPF 001 (HMO)	Miami-Dade MAPD	SOLIS SPF 001 (HMO)	Miami-Dade MAPD	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	002	0	2021	01	SOLIS SPF 002 (HMO D-SNP)	Miami-Dade D-SNP	SOLIS SPF 002 (HMO D-SNP)	Miami-Dade D-SNP	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	005	0	2021	01	SOLIS SPF 005 (HMO)	Orange MAPD	SOLIS SPF 005 (HMO)	Orange MAPD	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	006	0	2021	01	SOLIS SPF 006 (HMO D-SNP)	Orange D-SNP	SOLIS SPF 006 (HMO D-SNP)	Orange D-SNP	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	007	0	2021	01	SOLIS SPF 007 (HMO)	Broward MAPD	SOLIS SPF 007 (HMO)	Broward MAPD	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	008	0	2021	01	SOLIS SPF 008 (HMO)	Palm Beach MAPD	SOLIS SPF 008 (HMO)	Palm Beach MAPD	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	009	0	2021	01	SOLIS SPF 009 (HMO)	Hillsborough MAPD	SOLIS SPF 009 (HMO)	Hillsborough MAPD	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	010	0	2021	01	SOLIS SPF 010 (HMO D-SNP)	Hillsborough D-SNP	SOLIS SPF 010 (HMO D-SNP)	Hillsborough D-SNP	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	011	0	2021	01	SOLIS SPF 011 (HMO C-SNP)	Miami-Dade C-SNP	SOLIS SPF 011 (HMO C-SNP)	Miami-Dade C-SNP	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	012	0	2021	01	SOLIS SPF 012 (HMO D-SNP)	Broward D-SNP	SOLIS SPF 012 (HMO D-SNP)	Broward D-SNP	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H0982	013	0	2021	01	SOLIS SPF 013 (HMO D-SNP)	Palm Beach D-SNP	SOLIS SPF 013 (HMO D-SNP)	Palm Beach D-SNP	1	0	0	9250 NW 36th Street	Suite 400	Miami	FL	33178		info@solishealthplans.com	info@solishealthplans.com	9250 NW 36th Street	Suite 400	Miami	FL	33178				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://solishealthplans.com	1	3	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://solishealthplans.com	https://solishealthplans.com	https://solishealthplans.com
H1016	001	0	2021	01	AvMed Medicare Choice (HMO)	Miami-Dade County	AvMed Medicare Choice (HMO)	Miami-Dade County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	021	0	2021	01	AvMed Medicare Choice (HMO)	Broward County	AvMed Medicare Choice (HMO)	Broward County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	023	0	2021	01	AvMed Medicare Circle (HMO)	Miami-Dade County	AvMed Medicare Circle (HMO)	Miami-Dade County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	024	0	2021	01	AvMed Medicare Circle (HMO)	Broward County	AvMed Medicare Circle (HMO)	Broward County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	025	0	2021	02	AvMed Medicare Access (HMO-POS)	Miami-Dade County	AvMed Medicare Access (HMO-POS)	Miami-Dade County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.avmed.org	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	026	0	2021	02	AvMed Medicare Access (HMO-POS)	Broward County	AvMed Medicare Access (HMO-POS)	Broward County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.avmed.org	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	028	0	2021	01	AvMed Medicare Premium Saver (HMO)	Broward County	AvMed Medicare Premium Saver (HMO)	Broward County	1	0	0	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	801	0	2021	01	AvMed Employer Group MAPD Plan (HMO)	AvMed Florida Employer Group Plan		AvMed Florida Employer Group Plan	1	3	1	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	802	0	2021	01	AvMed Employer Group MA Only Plan (HMO)	AvMed Florida Employer Group Plan		AvMed Florida Employer Group Plan	1	3	1	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org									2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	803	0	2021	01	AvMed Employer Group MAPD Non-CY Plan (HMO)	AvMed Florida  Employer Group Plan		AvMed Florida  Employer Group Plan	1	3	1	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org	2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1016	804	0	2021	01	AvMed Employer Group MA Only Non-CY Plan (HMO)	AvMed Florida Employer Group Plan		AvMed Florida Employer Group Plan	1	3	1	9400 S Dadeland Blvd	Suite 315	Miami	FL	33156		karell.delosrios@avmed.org	regulatory.correspondence@avmed.org									2000000000208002000308002000408002000508002000608002000709001300	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avmed.org	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.avmed.org	www.avmed.org	www.avmed.org
H1019	001	0	2021	01	CareOne (HMO)	Broward County		Broward County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	006	0	2021	01	CareOne PLUS (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	023	0	2021	01	CareNeeds PLUS (HMO D-SNP)	Broward, Miami-Dade, & Palm Beach Counties		Broward, Miami-Dade, & Palm Beach Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	026	0	2021	01	CareNeeds PLUS (HMO D-SNP)	Orlando & Tampa Area		Orlando & Tampa Area	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	043	0	2021	01	CareOne (HMO)	Brevard and Indian River counties		Brevard and Indian River counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	057	0	2021	02	CareOne PLUS (HMO-POS)	Orlando Area		Orlando Area	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.careplushealthplans.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	065	0	2021	01	CareFree (HMO)	Broward and Palm Beach counties		Broward and Palm Beach counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	069	0	2021	01	CareOne (HMO)	Clay and Duval Counties		Clay and Duval Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	073	0	2021	01	CareNeeds PLUS (HMO D-SNP)	Brevard, Clay, Duval, Indian River, & Volusia Co.		Brevard, Clay, Duval, Indian River, & Volusia Co.	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	3	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	076	0	2021	01	CareFree PLUS (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	089	0	2021	01	CareExtra (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	092	0	2021	01	CareFree (HMO)	Orlando Area		Orlando Area	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	094	0	2021	01	CareFree (HMO)	Clay and Duval Counties		Clay and Duval Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	098	0	2021	01	CareOne PLUS (HMO)	Volusia County		Volusia County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	099	0	2021	01	CareFree (HMO)	Volusia County		Volusia County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	102	0	2021	01	CareOne (HMO)	Palm Beach County		Palm Beach County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	103	1	2021	01	CareOne PLUS (HMO)	Polk County		Polk County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	103	2	2021	01	CareOne PLUS (HMO)	Polk County		Hillsborough, Pasco, and Pinellas Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	104	1	2021	01	CareFree (HMO)	Polk County		Polk County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	104	2	2021	01	CareFree (HMO)	Polk County		Hillsborough, Pasco, and Pinellas Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	105	0	2021	01	CareComplete (HMO C-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	4	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	106	0	2021	01	CareComplete (HMO C-SNP)	Broward and Palm Beach Counties		Broward and Palm Beach Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	4	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	107	0	2021	01	CareComplete (HMO C-SNP)	Orlando & Tampa Area		Orlando & Tampa Area	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	108	0	2021	01	CareComplete (HMO C-SNP)	Brevard, Indian River, & Volusia Counties		Brevard, Indian River, & Volusia Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	109	0	2021	01	CareComplete (HMO C-SNP)	Clay and Duval Counties		Clay and Duval Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	1	4	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	110	0	2021	02	CareOne PLATINUM (HMO-POS)	Brevard and Indian River Counties		Brevard and Indian River Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.careplushealthplans.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	111	0	2021	01	CareOne PLATINUM (HMO)	Hillsborough, Pasco, and Pinellas Counties		Hillsborough, Pasco, and Pinellas Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	112	0	2021	01	CareOne PLATINUM (HMO)	Orlando Area		Orlando Area	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1019	113	0	2021	01	CareOne PLATINUM (HMO)	Clay and Duval Counties		Clay and Duval Counties	1	0	0	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	11430 NW 20th St., Ste. 300		Miami	FL	33172			cphp_memberservices@careplus-hp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.careplushealthplans.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.careplushealthplans.com/physician-finder	www.careplushealthplans.com/pharmacy-finder	www.careplushealthplans.com/medicare-plans/2019-prescription-drug-guides
H1032	040	0	2021	01	WellCare Dividend (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	124	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	170	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	175	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	176	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	182	0	2021	01	WellCare Select (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	184	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	186	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	189	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	190	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	191	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	192	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	193	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	194	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	195	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	196	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	197	0	2021	01	WellCare Reserve (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	198	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	199	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	200	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	201	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	202	0	2021	01	WellCare Reserve (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	203	0	2021	01	WellCare Champion (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	204	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	205	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	206	0	2021	01	WellCare Reserve (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	209	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	210	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	211	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	212	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	213	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	214	0	2021	01	WellCare Reserve (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	215	0	2021	01	WellCare Dividend Prime (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	216	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	217	0	2021	01	WellCare Reserve (HMO D-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	218	0	2021	01	WellCare Elite (HMO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	224	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	225	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	226	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	227	0	2021	01	WellCare Champion (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	228	0	2021	01	WellCare Champion (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	229	1	2021	01	WellCare Select (HMO D-SNP)	Select counties in FL		Segment 001	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	229	2	2021	01	WellCare Select (HMO D-SNP)	Select counties in FL		Segment 002	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	229	3	2021	01	WellCare Select (HMO D-SNP)	Select counties in FL		Segment 003	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	230	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	231	0	2021	01	WellCare Champion (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	232	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1032	233	0	2021	01	WellCare Champion (HMO C-SNP)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1035	002	0	2021	02	FHCP Medicare Rx Plus (HMO-POS)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	006	0	2021	01	FHCP Medicare Rx (HMO)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	011	0	2021	01	FHCP Medicare Premier Plus (HMO)	Brevard and Seminole counties		Brevard and Seminole counties	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	014	0	2021	01	FHCP Medicare Rx Savings (HMO)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	016	0	2021	01	FHCP Medicare Flagler Advantage (HMO)	St. Johns County		St. Johns County	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	017	0	2021	01	BlueMedicare Classic (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	018	0	2021	01	BlueMedicare Classic (HMO)	Palm Beach County		Palm Beach County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	019	0	2021	01	BlueMedicare Classic (HMO)	South, Central and North East Florida counties		South, Central and North East Florida counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	020	0	2021	01	BlueMedicare Classic (HMO)	Orange, Osceola & Seminole counties		Orange, Osceola & Seminole counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	021	0	2021	01	BlueMedicare Classic (HMO)	Hillsborough, Hernando, Pasco, & Polk counties		Hillsborough, Hernando, Pasco, & Polk counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	022	0	2021	01	BlueMedicare Premier (HMO)	Palm Beach County		Palm Beach County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	023	0	2021	01	BlueMedicare Premier (HMO)	Hillsborough and Polk counties		Hillsborough and Polk counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	024	0	2021	01	BlueMedicare Premier (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	025	0	2021	01	BlueMedicare Premier (HMO)	Broward County		Broward County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	026	0	2021	01	BlueMedicare Premier (HMO)	Orange & Osceola counties		Orange & Osceola counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	027	0	2021	01	BlueMedicare Complete (HMO D-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	028	0	2021	01	BlueMedicare Complete (HMO D-SNP)	Broward and Palm Beach counties		Broward and Palm Beach counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	029	0	2021	01	BlueMedicare Complete (HMO D-SNP)	Brevard, Orange, & Osceola counties		Brevard, Orange, & Osceola counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	030	0	2021	01	BlueMedicare Complete (HMO D-SNP)	Hillsborough and Polk counties		Hillsborough and Polk counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	031	0	2021	01	BlueMedicare Complete (HMO D-SNP)	Clay, Duval & Marion Counties		Clay, Duval & Marion Counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	032	0	2021	01	BlueMedicare Complete (HMO D-SNP)	Collier, Hernando, Pasco & Pinellas counties		Collier, Hernando, Pasco & Pinellas counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	033	0	2021	01	BlueMedicare Premier (HMO)	Clay & Duval counties		Clay & Duval counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	034	0	2021	01	BlueMedicare Premier (HMO)	Hernando, Pasco & Pinellas counties		Hernando, Pasco & Pinellas counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	035	0	2021	01	BlueMedicare Saver (HMO)	Broward & Palm Beach counties		Broward & Palm Beach counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	037	0	2021	01	BlueMedicare Saver (HMO)	Hillsborough, Pinellas & Polk Counties		Hillsborough, Pinellas & Polk Counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	038	0	2021	01	BlueMedicare Saver (HMO)	Orange & Osceola counties		Orange & Osceola counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	039	0	2021	01	BlueMedicare Saver (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	040	0	2021	01	FHCP Medicare Premier Advantage (HMO)	Brevard and Seminole counties		Brevard and Seminole counties	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	043	0	2021	01	BlueMedicare Premier (HMO)	Lake, Marion, & Sumter counties		Lake, Marion, & Sumter counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	044	0	2021	02	FHCP Medicare Choice (HMO-POS)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	1510 Ridgewood Avenue		Holly Hill	FL	32117		FHCPQuestions@fhcp.com	MemberServices@fhcp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.fhcpmedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.fhcpmedicare.com	www.fhcpmedicare.com	www.fhcpmedicare.com
H1035	045	0	2021	01	BlueMedicare Premier (HMO)	Manatee & Sarasota counties		Manatee & Sarasota counties	1	0	0	4800 Deerwood Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	801	0	2021	01	BlueMedicare Group HMO (HMO)	Florida		Florida	1	3	1	4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1035	802	0	2021	01	BlueMedicare Group HMO (HMO)	Florida		Florida	1	3	1	4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H1036	025	0	2021	01	Humana Gold Plus H1036-025 (HMO)	Tampa Metro Area		Tampa Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	044	0	2021	01	Humana Gold Plus H1036-044 (HMO)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	054	0	2021	01	Humana Gold Plus H1036-054C (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	056	0	2021	01	Humana Honor (HMO)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	062	0	2021	01	Humana Gold Plus H1036-062C (HMO)	Palm Beach County		Palm Beach County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	065	0	2021	01	Humana Gold Plus H1036-065C (HMO)	Broward County		Broward County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	068	0	2021	01	Humana Gold Plus H1036-068 (HMO)	Jacksonville Area		Jacksonville Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	074	0	2021	01	Humana Gold Plus H1036-074 (HMO)	Manatee and Sarasota Counties		Manatee and Sarasota Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	077	0	2021	01	Humana Gold Plus SNP-DE H1036-077A (HMO D-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	081	0	2021	01	Humana Gold Plus H1036-081D (HMO)	Baker, Duval and Nassau counties		Baker, Duval and Nassau counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	102	0	2021	01	Humana Gold Plus SNP-DE H1036-102 (HMO D-SNP)	Tampa Metro Area		Tampa Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	103	0	2021	01	Humana Gold Plus SNP-DE H1036-103A (HMO D-SNP)	Broward County		Broward County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	104	0	2021	01	Humana Gold Plus SNP-DE H1036-104A (HMO D-SNP)	Palm Beach County		Palm Beach County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	119	0	2021	01	Humana Honor (HMO)	Tampa Metro Area		Tampa Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	121	0	2021	01	Humana Gold Plus - Diabetes (HMO C-SNP)	Broward, Miami-Dade, and Palm Beach counties		Broward, Miami-Dade, and Palm Beach counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	137	0	2021	01	Humana Gold Plus H1036-137 (HMO)	Charlotte Metro Area		Charlotte Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	140	0	2021	01	Humana Gold Plus H1036-140 (HMO)	Citrus County		Citrus County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	143	0	2021	01	Humana Gold Plus H1036-143 (HMO)	Select counties of Panhandle East		Select counties of Panhandle East	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	146	0	2021	01	Humana Gold Plus H1036-146 (HMO)	Orange, Osceola and Seminole counties		Orange, Osceola and Seminole counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	151	0	2021	01	Humana Gold Plus H1036-151 (HMO)	Jackson Metro Area		Jackson Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	153	0	2021	01	Humana Gold Plus H1036-153 (HMO)	Portland Metro Area		Portland Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	156	0	2021	01	Humana Gold Plus - Diabetes (HMO C-SNP)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	157	0	2021	01	Humana Gold Plus H1036-157 (HMO)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	160	0	2021	01	Humana Gold Plus - Diabetes (HMO C-SNP)	Tampa Metro Area		Tampa Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	167	0	2021	01	Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP)	Charlotte Metro Area		Charlotte Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	168	0	2021	01	Humana Gold Plus SNP-DE H1036-168 (HMO D-SNP)	Greensboro / Winston-Salem Metro Area		Greensboro / Winston-Salem Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	171	0	2021	01	Humana Gold Plus H1036-171 (HMO)	Gulf Coast Area		Gulf Coast Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	175	0	2021	01	Humana Gold Plus - Diabetes (HMO C-SNP)	Jacksonville Area		Jacksonville Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	199	0	2021	01	Humana Gold Plus H1036-199 (HMO)	Palm Beach County		Palm Beach County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	209	0	2021	01	Humana Gold Plus SNP-DE H1036-209 (HMO D-SNP)	Flagler and Volusia counties		Flagler and Volusia counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	210	0	2021	01	Humana Gold Plus SNP-DE H1036-210 (HMO D-SNP)	Jacksonville Area		Jacksonville Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	213	0	2021	01	Humana Gold Plus SNP-DE H1036-213 (HMO D-SNP)	Greater Orlando		Greater Orlando	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	214	0	2021	01	Humana Gold Plus SNP-DE H1036-214 (HMO D-SNP)	Certain Panhandle Counties		Certain Panhandle Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	217	0	2021	01	Humana Gold Plus H1036-217 (HMO)	Charlotte, Collier and Lee counties		Charlotte, Collier and Lee counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	219	0	2021	01	Humana Gold Plus H1036-219 (HMO)	Deschutes and Jefferson counties		Deschutes and Jefferson counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	222	0	2021	01	Humana Gold Plus SNP-DE H1036-222 (HMO D-SNP)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	223	0	2021	01	Humana Gold Plus H1036-223 (HMO)	DeSoto County		DeSoto County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	226	0	2021	01	Humana Gold Plus SNP-DE H1036-226 (HMO D-SNP)	Glades, Martin, Okeechobee and St. Lucie counties		Glades, Martin, Okeechobee and St. Lucie counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	229	0	2021	01	Humana Gold Plus H1036-229 (HMO)	Glades, Martin, Okeechobee and St. Lucie counties		Glades, Martin, Okeechobee and St. Lucie counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	230	0	2021	01	Humana Gold Plus H1036-230 (HMO)	Hardee, Highlands and Polk counties		Hardee, Highlands and Polk counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	231	0	2021	01	Humana Gold Plus SNP-DE H1036-231 (HMO D-SNP)	Hardee, Highlands and Polk counties		Hardee, Highlands and Polk counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	233	0	2021	01	Humana Gold Plus H1036-233 (HMO)	Raleigh Metro Area		Raleigh Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	234	0	2021	01	Humana Community HMO Diabetes and Heart (HMO C-SNP)	Jefferson County		Jefferson County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	235	0	2021	01	Humana Community HMO SNP-DE (HMO D-SNP)	Jefferson County		Jefferson County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	236	0	2021	01	Humana Community (HMO)	Jefferson County		Jefferson County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	237	1	2021	01	Humana Gold Plus H1036-237 (HMO)	South Florida: Broward or Miami-Dade		South Florida- Broward	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	237	2	2021	01	Humana Gold Plus H1036-237 (HMO)	South Florida: Broward or Miami-Dade		South Florida- Miami-Dade	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	243	0	2021	01	Humana Gold Plus SNP-DE H1036-243 (HMO D-SNP)	Jacksonville Area		Jacksonville Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	245	0	2021	01	Humana Gold Plus SNP-DE H1036-245 (HMO D-SNP)	Certain Panhandle Counties		Certain Panhandle Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	249	0	2021	01	Humana Gold Plus SNP-DE H1036-249 (HMO D-SNP)	Glades, Martin, Okeechobee and St. Lucie counties		Glades, Martin, Okeechobee and St. Lucie counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	261	0	2021	01	Humana Gold Plus SNP-DE H1036-261 (HMO D-SNP)	Sarasota County		Sarasota County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	262	0	2021	01	Humana Gold Plus SNP-DE H1036-262 (HMO D-SNP)	Sarasota County		Sarasota County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	265	1	2021	01	Humana Gold Plus H1036-265 (HMO)	Tampa Metro Area		Tampa Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	265	2	2021	01	Humana Gold Plus H1036-265 (HMO)	Tampa Metro Area		Manatee and Sarasota Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	266	0	2021	01	Humana Gold Plus H1036-266 (HMO)	Citrus County		Citrus County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	268	0	2021	01	Humana Gold Plus H1036-268 (HMO)	Hardee, Highlands and Polk counties		Hardee, Highlands and Polk counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	269	0	2021	01	Humana Gold Plus H1036-269 (HMO)	Greater Orlando		Greater Orlando	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	270	0	2021	01	Humana Gold Plus H1036-270 (HMO)	Jacksonville Area		Jacksonville Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	271	0	2021	01	Humana Gold Plus H1036-271 (HMO)	Select counties of Panhandle East		Select counties of Panhandle East	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	276	0	2021	01	Humana Gold Plus SNP-DE H1036-276 (HMO D-SNP)	Raleigh Metro Area		Raleigh Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	277	0	2021	01	Humana Gold Plus H1036-277 (HMO)	Lake, Marion and Sumter counties		Lake, Marion and Sumter counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	278	0	2021	01	Humana Gold Plus H1036-278 (HMO)	Charlotte, Collier and Lee counties		Charlotte, Collier and Lee counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	279	0	2021	01	Humana Honor (HMO)	Broward and Palm Beach counties		Broward and Palm Beach counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	280	0	2021	01	Humana Fully Integrated H1036-280 (HMO D-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	281	0	2021	01	Humana Fully Integrated H1036-281 (HMO D-SNP)	Palm Beach County		Palm Beach County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	282	0	2021	01	Humana Fully Integrated H1036-282 (HMO D-SNP)	Broward County		Broward County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	283	0	2021	01	Humana Fully Integrated H1036-283 (HMO D-SNP)	Select Counties in Central Florida		Select Counties in Central Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	284	0	2021	01	Humana Gold Plus SNP-DE H1036-284 (HMO D-SNP)	Charlotte, Collier and Lee counties		Charlotte, Collier and Lee counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	285	0	2021	01	Humana Gold Plus SNP-DE H1036-285 (HMO D-SNP)	Charlotte, Collier and Lee counties		Charlotte, Collier and Lee counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	286	0	2021	01	Humana Gold Plus H1036-286-000 (HMO)	St. Lucie County		St. Lucie County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	287	0	2021	01	Humana Honor (HMO)	Escambia, Santa Rosa, Bay, Walton, Okaloosa		Escambia, Santa Rosa, Bay, Walton, Okaloosa	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	288	0	2021	01	Humana Honor (HMO)	Charlotte, Collier, Lee		Charlotte, Collier, Lee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	289	0	2021	01	Humana Honor (HMO)	Hardee, Highlands and Polk counties		Hardee, Highlands and Polk counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	290	0	2021	01	Humana Honor (HMO)	Greater Orlando		Greater Orlando	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	291	0	2021	01	Humana Gold Plus H1036-291 (HMO)	Greensboro - Winston Salem Metro Area		Greensboro - Winston Salem Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	801	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	806	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	810	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in MS, OR and NC		Select Counties in MS, OR and NC	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	811	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in MS, OR and NC		Select Counties in MS, OR and NC	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	814	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	815	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	816	0	2021	01	Humana Medicare Employer (HMO)	Select counties in MS, OR and NC		Select counties in MS, OR and NC	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	817	0	2021	01	Humana Medicare Employer (HMO)	Select counties in MS, OR and NC		Select counties in MS, OR and NC	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	818	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	819	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	820	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	821	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	822	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	823	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	824	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	825	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	826	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1036	827	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1043	001	0	2021	20	Florida PACE Centers, Inc. (PACE)	Florida PACE Centers, Inc.		Florida PACE Centers, Inc.	1	3	0									5200 NE 2nd Avenue		Miami	FL	33137		lalcure@mjhha.org	lrivera@miamijewishhealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	miamijewishhealthsystems.org	0	0	1			0					3	0	0		www.floridapace.org	www.noformulary.com
H1043	002	0	2021	20	Florida PACE Centers, Inc (PACE)	Florida PACE Centers, Inc.		Florida PACE Centers, Inc.	1	3	0									5200 NE 2nd Avenue		Miami	FL	33137		LAlcure@mjhha.org	lrivera@miamijewishhealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	miamijewishhealthsystems.org	0	0	1			0					3	0	0		www.floridapace.org	www.noformulary.com
H1045	001	0	2021	01	Preferred Choice Dade (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	005	0	2021	01	Preferred Choice Broward (HMO)	Broward County		Broward County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	012	0	2021	01	Preferred Medicare Assist Plan 1 (HMO D-SNP)	Miami-Dade and Broward Counties		Miami-Dade and Broward Counties	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	018	0	2021	01	Preferred Special Care Miami-Dade (HMO C-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	025	0	2021	01	UnitedHealthcare The Villages Medicare Advantage (HMO)	Lake, Marion and Sumter counties		Lake, Marion and Sumter counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	026	0	2021	02	AARP Medicare Advantage (HMO-POS)	Select Counties in Jacksonville		Select Counties in Jacksonville	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	028	0	2021	02	AARP Medicare Advantage (HMO-POS)	Select Counties in Central Florida		Select Counties in Central Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	030	0	2021	02	AARP Medicare Advantage (HMO-POS)	Brevard, Orange, Osceola and Seminole counties		Brevard, Orange, Osceola and Seminole counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	031	0	2021	02	AARP Medicare Advantage (HMO-POS)	Escambia, Okaloosa and Santa Rosa counties		Escambia, Okaloosa and Santa Rosa counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	032	0	2021	02	AARP Medicare Advantage (HMO-POS)	Bay and Walton counties		Bay and Walton counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	033	0	2021	01	AARP Medicare Advantage (HMO)	Select counties in Gainesville		Select counties in Gainesville	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	034	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select counties in Fort Myers/Naples Florida		Select counties in Fort Myers/Naples Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	036	0	2021	02	AARP Medicare Advantage Focus (HMO-POS)	Indian River, Martin and St. Lucie counties		Indian River, Martin and St. Lucie counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	037	0	2021	01	Preferred Choice Palm Beach (HMO)	Palm Beach county		Palm Beach county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	038	0	2021	01	Preferred Medicare Assist Palm Beach (HMO D-SNP)	Palm Beach county		Palm Beach county	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	039	0	2021	01	UnitedHealthcare Dual Complete LP (HMO D-SNP)	Select counties in Central Florida		Select counties in Central Florida	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H1045	041	0	2021	02	AARP Medicare Advantage (HMO-POS)	Select counties in Tallahassee		Select counties in Tallahassee	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	042	0	2021	02	AARP Medicare Advantage (HMO-POS)	DeSoto, Highlands, and Hardee counties		DeSoto, Highlands, and Hardee counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	043	0	2021	02	AARP Medicare Advantage (HMO-POS)	Citrus and Levy counties		Citrus and Levy counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	045	0	2021	02	AARP Medicare Advantage Focus (HMO-POS)	Select Counties in Tampa		Select Counties in Tampa	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1045	046	0	2021	01	Preferred Complete Care (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.myPreferredCare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.myPreferredCare.com	www.myPreferredCare.com	www.myPreferredCare.com
H1045	048	1	2021	01	UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)	State of Florida		Orlando Metro	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	048	2	2021	01	UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)	State of Florida		Southwest Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	048	3	2021	01	UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)	State of Florida		Tampa Metro	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	048	4	2021	01	UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)	State of Florida		Lake, Marion & Sumter Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	053	0	2021	01	Preferred Medicare Assist Plan 2 (HMO D-SNP)	Broward and Dade		Broward and Dade	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	802	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1045	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Florida		Select counties in Florida	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1099	001	0	2021	02	Health First Classic Plan (HMO-POS)	Counties: BR, IR	Health First Classic Plan (HMO-POS)	Counties: BR, IR	1	0	0	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	myHFHP.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	myHFHP.org	myHFHP.org	myHFHP.org
H1099	006	0	2021	01	Health First Value Plan (HMO)	Counties: BR, IR	Health First Value Plan (HMO)	Counties: BR, IR	1	0	0	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myHFHP.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	myHFHP.org	myHFHP.org	myHFHP.org
H1099	009	0	2021	01	Health First Secure Plan (HMO)	Counties: BR, IR	Health First Secure Plan (HMO)	Counties: BR, IR	1	0	0	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org									2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myHFHP.org	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	myHFHP.org	myHFHP.org	myHFHP.org
H1099	014	0	2021	01	Health First Rewards Plan (HMO)	Counties: BR, IR	Health First Rewards Plan (HMO)	Counties: BR, IR	1	0	0	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myHFHP.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	myHFHP.org	myHFHP.org	myHFHP.org
H1099	016	0	2021	01	AdventHealth SunSaver Plan (HMO)	Counties: VO, FL, HA, HI, SE	AdventHealth SunSaver Plan (HMO)	Counties: VO, FL, HA, HI, SE	1	0	0	AdventHealth Advantage Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	AdventHealth Advantage Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myAHplan.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	myAHplan.com	myAHplan.com	myAHplan.com
H1099	802	0	2021	01	Employer Group Plus (HMO)	Central Florida Area	Employer Group Plus (HMO)	Central Florida Area	1	3	1	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myHFHP.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	myHFHP.org	myHFHP.org	myHFHP.org
H1099	804	0	2021	02	Employer Group POS (HMO-POS)	Central Florida Area	Employer Group POS (HMO-POS)	Central Florida Area	1	3	1	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	Health First Health Plans	6450 US Highway 1	Rockledge	FL	32955		HFHPInfo@HF.org	HFHPInfo@HF.org	2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	myHFHP.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	myHFHP.org	myHFHP.org	myHFHP.org
H1100	001	0	2021	04	Innovation Health-Aetna Medicare Voyager (PPO)	Fairfax County and Surrounding Area		Fairfax County and Surrounding Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.innovationhealthmedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.innovationhealthmedicare.com/findprovider	www.innovationhealthmedicare.com/findpharmacy	www.innovationhealthmedicare.com/formulary
H1100	002	0	2021	04	Innovation Health-Aetna Medicare Premier (PPO)	Fairfax County and Surrounding Area		Fairfax County and Surrounding Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.innovationhealthmedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.innovationhealthmedicare.com/findprovider	www.innovationhealthmedicare.com/findpharmacy	www.innovationhealthmedicare.com/formulary
H1109	005	0	2021	01	Aetna Medicare Select Plan (HMO)	Select Counties in Atlanta and Macon area		Select Counties in Atlanta and Macon area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1109	006	0	2021	01	Aetna Medicare Select Plan (HMO)	Hall County		Hall County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1109	801	0	2021	01	Aetna Medicare Plan (HMO)	Georgia		Georgia	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1109	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Georgia		Georgia	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1111	009	1	2021	01	AARP Medicare Advantage Walgreens (HMO)	Select counties in Georgia		Cobb, DeKalb, and Fulton Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1111	009	2	2021	01	AARP Medicare Advantage Walgreens (HMO)	Select counties in Georgia		Select Counties in Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1111	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	GA Employer Sponsored Plan Service Area		GA Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1111	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	GA Employer Sponsored Plan Service Area		GA Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1111	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	GA Employer Sponsored Plan Service Area		GA Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1111	807	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	GA Employer Sponsored Plan Service Area		GA Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1112	006	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	033	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	034	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	035	0	2021	01	WellCare Choice (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	037	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	038	0	2021	01	WellCare Value (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	039	0	2021	01	WellCare Value (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	040	0	2021	01	WellCare Focus (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	042	0	2021	01	WellCare Dividend (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	043	0	2021	01	WellCare Compass (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1112	044	0	2021	01	WellCare Value (HMO)	Select counties in GA		Select counties in GA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1119	001	0	2021	01	Valor Health Plan (HMO I-SNP)	Northeast and Central Ohio		Northeast and Central Ohio	1	0	0	One Riverfront Place, Suite 525		Little Rock	AR	72114		info@valorhealthplan.com	info@valorhealthplan.com	One Riverfront Place, Suite 525		Little Rock	AR	72114		info@valorhealthplan.com	info@valorhealthplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.valorhealthplan.com	1	1	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.valorhealthplan.com	www.valorhealthplan.com	www.valorhealthplan.com
H1142	001	0	2021	01	Bright Advantage (HMO)	Cincinnati, Toledo, and Youngstown Metro Areas		Cincinnati, Toledo, and Youngstown Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1142	002	0	2021	01	Bright Advantage Plus (HMO)	Cincinnati, Toledo, and Youngstown Metro Areas		Cincinnati, Toledo, and Youngstown Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1142	003	0	2021	01	Bright Advantage University Hospitals (HMO)	Cleveland and Akron Metro Areas		Cleveland and Akron Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1142	013	0	2021	01	Bright Advantage (HMO)	Lorain County		Lorain County	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1142	801	0	2021	01	Bright Advantage University Hospitals Group (HMO)	Cleveland and Akron Metro Areas		Cleveland and Akron Metro Areas	1	3	1	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1170	002	0	2021	01	Kaiser Permanente Senior Advantage Enhanced (HMO)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1170	008	0	2021	01	Senior Advantage Medicare Medicaid Plan (HMO D-SNP)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	3	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1170	009	0	2021	01	Kaiser Permanente Senior Advantage Basic (HMO)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1170	801	0	2021	01	Kaiser Permanente Employer Group Plan (HMO)	Atlanta Metro Area		Atlanta Metro Area	1	3	1	3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1170	802	0	2021	01	Kaiser Employer Group With Part D (HMO)	Atlanta Metro Area		Atlanta Metro Area	1	3	1	3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				3495 Piedmont Road Northeast	Building 9	Atlanta	GA	30305				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1170	805	0	2021	01	FEHB Part AB  with D (HMO)	Atlanta Metro Area		Atlanta Metro Area	1	3	1	3495 Piedmont Road	Building 10	Atlanta	GA	30305				3495 Piedmont Road	Building 10	Atlanta	GA	30305				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1181	001	0	2021	07	NetworkPrime (MSA)	Wisconsin		Wisconsin	1	3	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1189	001	0	2021	01	CHRISTUS Health Plan Generations (HMO)	North Central New Mexico		North Central New Mexico	1	0	0	P.O. Box 169009		Irving	TX	75016				P.O. Box 169009		Irving	TX	75016				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.christushealthplan.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.christushealthplan.org	www.christushealthplan.org
H1189	002	0	2021	01	CHRISTUS Health Plan Generations Plus (HMO)	North Central New Mexico		North Central New Mexico	1	0	0	P.O. Box 169009		Irving	TX	75016				P.O. Box 169009		Irving	TX	75016				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.christushealthplan.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.christushealthplan.org	www.christushealthplan.org
H1189	003	0	2021	01	CHRISTUS Health Plan Generations (HMO)	North East Texas		North East Texas	1	0	0	P.O. Box 169009		Irving	TX	75016				P.O. Box 169009		Irving	TX	75016				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.christushealthplan.org/	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.christushealthplan.org	www.christushealthplan.org
H1189	004	0	2021	01	CHRISTUS Health Plan Generations Plus (HMO)	North East Texas		North East Texas	1	0	0	P.O. Box 169009		Irving	TX	75016				P.O. Box 169009		Irving	TX	75016				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.christushealthplan.org/	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.christushealthplan.org	www.christushealthplan.org
H1205	001	0	2021	01	Integra Harmony (HMO D-SNP)	Bronx, Kings, Queens and New York counties		Bronx, Kings, Queens and New York counties	1	0	0	1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.integramanagedcare.com	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.integramanagedcare.com/provider-search	www.integramanagedcare.com/provider-search	client.formularynavigator.com/Search.aspx?siteCode=3037733490
H1205	002	0	2021	01	Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)	Bronx, Kings, Queens and New York counties		Bronx, Kings, Queens and New York counties	1	0	0	1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.integramanagedcare.com	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.integramanagedcare.com/provider-search	www.integramanagedcare.com/provider-search	client.formularynavigator.com/Search.aspx?siteCode=3037733490
H1205	005	0	2021	01	Integra Harmony (HMO D-SNP)	Nassau County		Nassau County	1	0	0	1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.integramanagedcare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.integramanagedcare.com/provider-search	www.integramanagedcare.com/provider-search	client.formularynavigator.com/Search.aspx?siteCode=3037733490
H1205	006	0	2021	01	Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)	Nassau County		Nassau County	1	0	0	1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.integramanagedcare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.integramanagedcare.com/provider-search	www.integramanagedcare.com/provider-search	client.formularynavigator.com/Search.aspx?siteCode=3037733490
H1205	007	0	2021	01	Integra Balanced Medicaid Advantage (HMO D-SNP)	Bronx, Kings, Queens, and New York counties		Bronx, Kings, Queens, and New York counties	1	0	0	1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.integramanagedcare.com	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	integramanagedcare.com/provider-search	integramanagedcare.com	integramanagedcare.com
H1205	008	0	2021	01	Integra Balanced Medicaid Advantage (HMO D-SNP)	Nassau County		Nassau County	1	0	0	1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				1981 Marcus Avenue	Suite 100	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.integramanagedcare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	integramanagedcare.com/provider-search	integramanagedcare.com	integramanagedcare.com
H1225	001	0	2021	01	Johns Hopkins Advantage MD (HMO)	Counties: AA BL CV CR FR HW MG SS WH WC WR		Counties: AA BL CV CR FR HW MG SS WH WC WR	1	0	0	P.O. Box 3538		Scranton	PA	18505				P.O. Box 3538		Scranton	PA	18505				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hopkinsmedicare.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/
H1225	002	0	2021	01	Johns Hopkins Advantage MD (HMO)	Baltimore City		Baltimore City	1	0	0	P.O. Box 3538		Scranton	PA	18505				P.O. Box 3538		Scranton	PA	18505				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hopkinsmedicare.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/
H1228	001	0	2021	20	Central Valley PACE - Dual Eligible (PACE)	Stanislaus and San Joaquin Counties California		Stanislaus and San Joaquin Counties California	1	3	0									2401 East Orangeburg Ave	Suite 330	Modesto Ca	CA	95355		info@cvpace.org	info@cvpace.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cvpace.org	0	0	1			0					3	0	0		N/A	N/A
H1228	002	0	2021	20	Central Valley PACE - Medicare Only (PACE)	Stanislaus and San Joaquin Counties California		Stanislaus and San Joaquin Counties California	1	3	0									2401 East Orangeburg Ave	Suite 330	Modesto Ca	CA	95355		info@cvpace.org	info@cvpace.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cvpace.org	0	0	1			0					3	0	0		N/A	N/A
H1230	001	0	2021	01	Kaiser Permanente Senior Advantage Enhanced (HMO)	Island of Oahu		Island of Oahu	1	0	0	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	003	0	2021	01	Kaiser Permanente Senior Advantage Basic (HMO)	Island of Oahu		Island of Oahu	1	0	0	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	008	0	2021	01	Senior Advantage Medicare Medicaid (HMO D-SNP)	Islands of Oahu and Maui		Islands of Oahu and Maui	1	0	0	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	013	0	2021	01	Kaiser Permanente Senior Advantage Maui (HMO)	Island of Maui		Island of Maui	1	0	0	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	3	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	014	0	2021	01	Kaiser Permanente Senior Advantage Hawaii Island (HMO)	Island of Hawaii except for 3 ZIPs		Island of Hawaii except for 3 ZIPs	1	0	0	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	3	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	801	0	2021	01	Kaiser Permanente Employer Group MA only (HMO)	Islands of Oahu, Maui and Hawaii except for 3 ZIPs		Islands of Oahu, Maui and Hawaii except for 3 ZIPs	1	3	1	711 Kapiolani Blvd		Honolulu	HI	96813												7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	803	0	2021	01	Kaiser Permanente Employer Group MA-PD (HMO)	Islands of Oahu, Maui and Hawaii except for 3 ZIPs		Islands of Oahu, Maui and Hawaii except for 3 ZIPs	1	3	1	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	804	0	2021	01	Kaiser Permanente Employer Group MA-PD Part B (HMO)	Islands of Oahu, Maui and Hawaii except for 3 ZIPs		Islands of Oahu, Maui and Hawaii except for 3 ZIPs	1	3	1	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	805	0	2021	01	FEHB AB with D (HMO)	Islands of Oahu, Maui and Hawaii except for 3 ZIPs		Islands of Oahu, Maui and Hawaii except for 3 ZIPs	1	3	1	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1230	806	0	2021	01	FEHB B only with D (HMO)	Islands of Oahu, Maui and Hawaii except for 3 ZIPs		Islands of Oahu, Maui and Hawaii except for 3 ZIPs	1	3	1	711 Kapiolani Blvd		Honolulu	HI	96813				711 Kapiolani Blvd		Honolulu	HI	96813				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H1234	001	0	2021	20	SFMC-Dual (PACE)	Mercer County and portions of Burlington County		Mercer County and portions of Burlington County	1	3	0									7500 K. Johnson Blvd		Bordentown	NJ	08505		lzavorski@stfrancismedical.org	lzavorski@stfrancismedical.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.stfrancismedical.org/LIFE	0	0	1			0					3	0	0		www.pharmastar.com	www.stfrancismedical.org
H1234	002	0	2021	20	SFMC-Medicare only (PACE)	Mercer County and portions of Burlington County		Mercer County and portions of Burlington County	1	3	0									7500 K. Johnson Blvd		Bordentown	NJ	08505		lzavorski@stfrancismedical.org	lzavorski@stfrancismedical.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.stfrancismedical.org/LIFE	0	0	1			0					3	0	0		www.pharmastar.com	www.stfrancismedical.org
H1239	001	0	2021	20	InnovAge Virginia PACE- Roanoke Valley (PACE)	Roanoke Valley Area		Roanoke Valley Area	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A
H1239	002	0	2021	20	InnovAge Virginia PACE- Roanoke Valley (PACE)	Roanoke Valley Area		Roanoke Valley Area	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A
H1248	001	0	2021	04	Blue Advantage (PPO)	Baton Rouge, Surrounding Parishes		Baton Rouge, Surrounding Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	002	0	2021	04	Blue Advantage (PPO)	New Orleans, Surrounding Parishes		New Orleans, Surrounding Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	003	0	2021	04	Blue Advantage (PPO)	Tangipahoa, St. Tammany, Washington Parishes		Tangipahoa, St. Tammany, Washington Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	004	0	2021	04	Blue Advantage (PPO)	Alexandria, LC, Lafayette, Surrounding Parishes		Alexandria, LC, Lafayette, Surrounding Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	005	0	2021	04	Blue Advantage (PPO)	Northwest Parishes		Northwest Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	006	0	2021	04	Blue Advantage (PPO)	Northeast Parishes		Northeast Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	801	0	2021	04	Blue Advantage (PPO)	State of Louisiana		State of Louisiana	1	3	1	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	802	0	2021	04	Blue Advantage (PPO)	State of Louisiana		State of Louisiana	1	3	1	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1248	803	0	2021	04	Blue Advantage (PPO)	State of Louisiana		State of Louisiana	1	3	1	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H1277	001	0	2021	01	Align Thrive (HMO I-SNP)	Virginia (partial)		Virginia (partial)	1	0	0	10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.alignseniorcare.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignseniorcare.com	www.PLACEHOLDER.com	www.PLACEHOLDER.com
H1277	002	0	2021	01	Align Connect (HMO C-SNP)	Virginia (partial)		Virginia (partial)	1	0	0	10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.alignseniorcare.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignseniorcare.com	www.PLACEHOLDER.com	www.PLACEHOLDER.com
H1278	001	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in IA and NE		Select Counties in IA and NE	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	003	0	2021	04	AARP Medicare Advantage Choice (PPO)	West Texas		West Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $255.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $255.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	004	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Austin Metro Area		Austin Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	005	0	2021	04	AARP Medicare Advantage Choice (PPO)	San Antonio Metro Area		San Antonio Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	007	0	2021	04	AARP Medicare Advantage Choice (PPO)	Sioux Falls Area		Sioux Falls Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	009	0	2021	04	AARP Medicare Advantage Choice (PPO)	Rapid City Area		Rapid City Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	010	0	2021	04	AARP Medicare Advantage Choice (PPO)	Brownsville Metro Area		Brownsville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $255.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $255.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	013	0	2021	04	AARP Medicare Advantage Choice (PPO)	Dallas Metro Area		Dallas Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	014	0	2021	04	AARP Medicare Advantage Choice (PPO)	Houston Metro Area		Houston Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	015	0	2021	04	AARP Medicare Advantage Choice (PPO)	Henderson, Smith, and Wood counties		Henderson, Smith, and Wood counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	016	0	2021	04	AARP Medicare Advantage Choice (PPO)	Corpus Christi Metro Area		Corpus Christi Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	018	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties in Nebraska		Select Counties in Nebraska	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1278	019	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties in IA, NE, and SD		Select Counties in IA, NE, and SD	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1290	001	0	2021	01	Devoted Health Core Miami-Dade (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	002	0	2021	01	Devoted Health Core Broward (HMO)	Broward County		Broward County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	003	0	2021	01	Devoted Health Core Palm Beach (HMO)	Palm Beach County		Palm Beach County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	004	0	2021	01	Devoted Health Core Greater Tampa Bay (HMO)	Greater Tampa Bay		Greater Tampa Bay	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	005	0	2021	01	Devoted Health Core Greater Orlando (HMO)	Osceola, Seminole, and Orange Counties		Osceola, Seminole, and Orange Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	006	0	2021	01	Devoted Health Prime Miami-Dade (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	007	0	2021	01	Devoted Health Prime Broward (HMO)	Broward County		Broward County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	008	0	2021	01	Devoted Health Prime Palm Beach (HMO)	Palm Beach County		Palm Beach County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	009	0	2021	01	Devoted Health Prime Greater Tampa Bay (HMO)	Greater Tampa Bay		Greater Tampa Bay	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	010	0	2021	01	Devoted Health Prime Greater Orlando (HMO)	Osceola, Seminole, Orange Counties		Osceola, Seminole, Orange Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	013	0	2021	01	Devoted Health Essentials Miami-Dade (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	014	0	2021	01	Devoted Health Essentials Broward (HMO)	Broward County		Broward County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	015	0	2021	01	Devoted Health Essentials Palm Beach (HMO)	Palm Beach County		Palm Beach County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	016	0	2021	01	Devoted Health Essentials Greater Tampa Bay (HMO)	Hillsborough,Pinellas, Hernando, & Pasco		Hillsborough,Pinellas, Hernando, & Pasco	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	017	0	2021	01	Devoted Health Essentials Polk (HMO)	Polk County		Polk County	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	018	0	2021	01	Devoted Health Essentials Greater Orlando (HMO)	Osceola, Seminole, and Orange Counties		Osceola, Seminole, and Orange Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	019	0	2021	01	Devoted Health Dual Miami-Dade (HMO D-SNP)	Miami-Dade		Miami-Dade	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	020	0	2021	01	Devoted Health Dual Broward (HMO D-SNP)	Broward		Broward	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	021	0	2021	01	Devoted Health Dual Palm Beach (HMO D-SNP)	Palm Beach		Palm Beach	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	022	0	2021	01	Devoted Health Dual Greater Orlando (HMO D-SNP)	Osceola, Seminole, and Orange Counties		Osceola, Seminole, and Orange Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	023	0	2021	01	Devoted Health Dual Greater Jacksonville (HMO D-SNP)	Clay, Duval, and Nassau Counties		Clay, Duval, and Nassau Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	024	0	2021	01	Devoted Health Dual Greater Tampa Bay (HMO D-SNP)	Hillsborough, Pinellas, and Polk counties		Hillsborough, Pinellas, and Polk counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	025	0	2021	01	Devoted Health Core Manatee (HMO)	Manatee		Manatee	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	026	0	2021	01	Devoted Health Prime Manatee (HMO)	Manatee		Manatee	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	027	0	2021	01	Devoted Health Core (HMO)	Lake, Marion, and Sumter Counties		Lake, Marion, and Sumter Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	028	0	2021	01	Devoted Health Prime (HMO)	Lake, Marion, and Sumter Counties		Lake, Marion, and Sumter Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	029	0	2021	01	Devoted Health Core Greater Jacksonville (HMO)	Clay, Duval, and Nassau Counties		Clay, Duval, and Nassau Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	030	0	2021	01	Devoted Health Prime Greater Jacksonville (HMO)	Clay, Duval, and Nassau Counties		Clay, Duval, and Nassau Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	031	0	2021	01	Devoted Health Essentials Greater Jacksonville (HMO)	Clay, Duval, and Nassau Counties		Clay, Duval, and Nassau Counties	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1290	032	0	2021	01	Devoted Health Essentials Manatee (HMO)	Manatee		Manatee	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H1302	004	0	2021	04	Secure Blue no Rx (PPO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	bcidaho.com/FindSecureBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1302	802	0	2021	04	Secure Blue Employer (PPO)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcidaho.com/medicare	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.bcidaho.com/medicare	bcidaho.com/ma_formulary	bcidaho.com/ma_formulary
H1304	001	0	2021	04	Regence Valiance (PPO)	Select Counties in Idaho/Asotin Co, WA		Select Counties in Idaho/Asotin Co, WA	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	004	0	2021	04	Regence MedAdvantage + Rx Enhanced (PPO)	Select Counties in Idaho/Asotin Co, WA		Select Counties in Idaho/Asotin Co, WA	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	011	1	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Select Counties in Idaho/Asotin Co, WA		South	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	011	2	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Select Counties in Idaho/Asotin Co, WA		North	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	012	1	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Select Counties in Idaho/Asotin Co, WA		South	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	012	2	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Select Counties in Idaho/Asotin Co, WA		North	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	803	0	2021	04	Regence MedAdvantage (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	804	0	2021	04	Regence MedAdvantage + Rx (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	805	0	2021	04	Regence MedAdvantage + Rx 02 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1304	806	0	2021	04	Regence MedAdvantage + Rx 03 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1310	001	0	2021	20	Senior Care Partners PACE Dual (PACE)	Greater Kalamazoo and Calhoun County Areas		Greater Kalamazoo and Calhoun County Areas	1	3	0									200 West Michigan Avenue	Suite 103	Battle Creek	MI	49017		a.lueth@SeniorCarePartnersMI.org	a.lueth@SeniorCarePartnersMI.org	2000000000207001700307001700407001700507001700607001700000000000	2000000000207001700307001700407001700507001700607001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePartnersMI.org	0	0	1			0					3	0	0		seniorcarepartnersmi.org	seniorcarepartnersmi.org
H1310	003	0	2021	20	Senior Care Partners PACE Medicare-only (PACE)	Greater Kalamazoo and Calhoun County Areas		Greater Kalamazoo and Calhoun County Areas	1	3	0									200 West Michigan Avenue	Suite 103	Battle Creek	MI	49017		a.lueth@SeniorCarePartnersMI.org	a.lueth@SeniorCarePartnersMI.org	2000000000207001700307001700407001700507001700607001700000000000	2000000000207001700307001700407001700507001700607001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePartnersMI.org	0	0	1			0					3	0	0		seniorcarepartnersmi.org	seniorcarepartnersmi.org
H1350	006	0	2021	01	True Blue no Rx (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	009	0	2021	01	True Blue Special Needs Plan (HMO D-SNP)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MACS@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MACS@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	idahotruebluesnp.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	bcidaho.com/FindSNPDoctors	bcidaho.com/FindASNPpharmacy	bcidaho.com/SNPDrugList
H1350	015	1	2021	01	True Blue Rx Option I (HMO)	Select Counties Idaho		Select Counties 1 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	015	2	2021	01	True Blue Rx Option I (HMO)	Select Counties Idaho		Select Counties 2 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	016	1	2021	01	True Blue Rx Option II (HMO)	Select Counties Idaho		Select Counties 1 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	016	2	2021	01	True Blue Rx Option II (HMO)	Select Counties Idaho		Select Counties 2 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	019	1	2021	01	True Blue Rx (HMO)	Select Counties Idaho		Select Counties 1 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	019	2	2021	01	True Blue Rx (HMO)	Select Counties Idaho		Select Counties 2 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	021	0	2021	01	True Blue Rx Preferred (HMO)	Ada and Canyon counties		Ada and Canyon counties	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $185.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $185.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBluePreferredDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	023	1	2021	01	True Blue Rx | St. Luke's Health Partners (HMO)	Select Counties in Idaho		Select Counties 1 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueStLukesHealthPartnersDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	023	2	2021	01	True Blue Rx | St. Luke's Health Partners (HMO)	Select Counties in Idaho		Select Counties 2 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueStLukesHealthPartnersDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	024	1	2021	01	True Blue Rx Gem (HMO)	Select Counties in Idaho		Select Counties 1 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	024	2	2021	01	True Blue Rx Gem (HMO)	Select Counties in Idaho		Select Counties 2 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	024	3	2021	01	True Blue Rx Gem (HMO)	Select Counties in Idaho		Select Counties 3 Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	025	0	2021	01	True Blue Special Needs Plan (HMO D-SNP)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	P.O. Box 8406		Boise	ID	83707		MACS@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MACS@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	idahotruebluesnp.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	bcidaho.com/FindSNPDoctors	bcidaho.com/FindASNPpharmacy	bcidaho.com/SNPDrugList
H1350	026	0	2021	01	True Blue Rx Essentials (HMO)	Ada and Canyon counties		Ada and Canyon counties	1	0	0	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	bcidaho.com/FindTrueBlueDoctors	bcidaho.com/FindAPharmacy	bcidaho.com/DrugList
H1350	803	0	2021	01	True Blue Employer (HMO)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	804	0	2021	01	True Blue Employer (HMO)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	805	0	2021	01	True Blue Employer (HMO)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	806	0	2021	02	True Blue Employer (HMO-POS)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	807	0	2021	02	True Blue Employer (HMO-POS)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	808	0	2021	01	True Blue Employer (HMO)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	809	0	2021	01	True Blue Employer (HMO)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	810	0	2021	02	True Blue Employer (HMO-POS)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1350	811	0	2021	02	True Blue Employer (HMO-POS)	Idaho		Idaho	1	3	1	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com	MACS@bcidaho.com	P.O. Box 8406		Boise	ID	83707		MABlue@bcidaho.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.bcidaho.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	medicare.bcidaho.com	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page	https://medicare.bcidaho.com/formulary-information/medicare-advantage-drug-lists.page
H1352	001	0	2021	01	Blue Medicare Advantage Complete (HMO)	Kansas City Area		Kansas City Area	1	0	0	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MedicareBlueKC.com	www.MedicareBlueKC.com	www.MedicareBlueKC.com
H1352	002	0	2021	01	Blue Medicare Advantage Plus (HMO)	Kansas City Area		Kansas City Area	1	0	0	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MedicareBlueKC.com	www.MedicareBlueKC.com	www.MedicareBlueKC.com
H1352	003	0	2021	01	Blue Medicare Advantage Spira Care (HMO)	Kansas City Area		Kansas City Area	1	0	0	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.MedicareBlueKC.com	www.MedicareBlueKC.com	www.MedicareBlueKC.com
H1352	801	0	2021	01	Blue Medicare Advantage Employer Group Plan MA-CY (HMO)	Kansas City Area		Kansas City Area	1	3	1	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.BlueKCMA.com	https://www.medicarebluekc.com/	https://www.medicarebluekc.com/
H1352	803	0	2021	01	Blue Medicare Advantage Employer Group Plan MAPDCY (HMO)	Kansas City Area		Kansas City Area	1	3	1	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.BlueKCMA.com	https://www.medicarebluekc.com/	https://www.medicarebluekc.com/
H1352	804	0	2021	01	Blue Medicare Advantage Employer Group Plan MAPDBY (HMO)	Kansas City Area		Kansas City Area	1	3	1	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.BlueKCMA.com	https://www.medicarebluekc.com/	https://www.medicarebluekc.com/
H1353	001	0	2021	01	WellCare Value (HMO)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1353	002	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1353	004	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1353	005	0	2021	01	WellCare Value (HMO)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1353	006	0	2021	01	WellCare Dividend (HMO)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1357	001	0	2021	20	Carolina SeniorCare (PACE)	Carolina SeniorCare	Carolina SeniorCare (PACE)	Carolina SeniorCare	1	3	0									802 East Center Street		Lexington	NC	27292		tchang@uchas.org	tchang@uchas.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.carolinaseniorcare.org/	0	0	1			0					3	0	0		https://www.carolinaseniorcare.org/	https://www.carolinaseniorcare.org/
H1357	002	0	2021	20	Carolina SeniorCare (PACE)	Carolina SeniorCare	Carolina SeniorCare (PACE)	Carolina SeniorCare	1	3	0									802 East Center Street		Lexington	NC	27292		tchang@uchas.org	tchang@uchas.org	2100001200200001200300001200400001200500001200600001200700001200	2100001200200001200300001200400001200500002000600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.carolinaseniorcare.org/	0	0	1			0					3	0	0		https://www.carolinaseniorcare.org/	https://www.carolinaseniorcare.org/
H1360	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Clark, Nye, Carson City and Washoe counties		Clark, Nye, Carson City and Washoe counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1365	001	0	2021	04	Martin's Point Generations Advantage Select (PPO)	Southern Maine & Southern New Hampshire		Southern Maine & Southern New Hampshire	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H1365	002	0	2021	04	Martin's Point Generations Advantage Select (PPO)	Northern Maine & Northern New Hampshire		Northern Maine & Northern New Hampshire	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H1365	802	0	2021	04	Martin's Point Generations Advantage Premier Group (PPO)	National		National	1	3	1	P.O. Box 9746	331 Veranda Street	Portland	ME	04104				P.O. Box 9746	331 Veranda Street	Portland	ME	04104				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H1365	803	0	2021	04	Martin's Point Generations Advantage Premier Group (PPO)	National		National	1	3	1	P.O. Box 9746	331 Veranda Street	Portland	ME	04104				P.O. Box 9746	331 Veranda Street	Portland	ME	04104				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H1372	001	0	2021	01	AgeRight Advantage Health Plan (HMO I-SNP)	OR Counties: CLK, KLA, LAN, MUL, WSH & YAM		OR Counties: CLK, KLA, LAN, MUL, WSH & YAM	1	0	0	PO Box 4440		Glen Allen	VA	23058				PO Box 4440		Glen Allen	VA	23058				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.agerightadvantage.com	1	1	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.agerightadvantage.com	www.agerightadvantage.com	www.agerightadvantage.com
H1375	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Alameda County		Alameda County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H1375	002	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Fresno, Kings, and Madera Counties		Fresno, Kings, and Madera Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H1393	001	0	2021	04	Bright Advantage Choice (PPO)	Nashville Metro Area		Nashville Metro Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1393	002	0	2021	04	Bright Advantage Choice Plus (PPO)	Nashville Metro Area		Nashville Metro Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1393	003	0	2021	04	Bright Advantage Choice (PPO)	Memphis Area		Memphis Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1393	004	0	2021	04	Bright Advantage Assist (PPO)	Memphis Area		Memphis Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H1415	013	0	2021	01	Cigna Fundamental Medicare (HMO)	Chicago Area	Cigna Fundamental Medicare (HMO)	Chicago Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H1415	021	0	2021	02	Cigna Premier Medicare (HMO-POS)	Chicago Area	Cigna Premier Medicare (HMO-POS)	Chicago Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H1415	024	0	2021	01	Cigna Preferred Medicare (HMO)	Chicago Area	Cigna Preferred Medicare (HMO)	Chicago Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H1416	009	0	2021	02	WellCare Value (HMO-POS)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	023	0	2021	01	WellCare Compass (HMO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	026	0	2021	02	WellCare Essential (HMO-POS)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	033	0	2021	02	WellCare Access (HMO-POS D-SNP)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	034	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	035	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in TN		Select counties in TN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	036	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	039	0	2021	01	WellCare Dividend (HMO)	Select counties in TN		Select counties in TN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	041	0	2021	01	WellCare Compass (HMO)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	042	0	2021	01	WellCare Compass (HMO)	Select counties in TN		Select counties in TN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	043	0	2021	02	WellCare Liberty (HMO-POS D-SNP)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	044	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	048	0	2021	01	WellCare Plus (HMO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	053	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	055	0	2021	01	WellCare Preferred (HMO)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	056	0	2021	01	WellCare Value (HMO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	057	0	2021	01	WellCare Value (HMO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	058	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	059	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	060	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	061	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in TN		Select counties in TN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	064	0	2021	01	WellCare Dividend (HMO)	Select counties in AR		Select counties in AR	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	065	0	2021	01	WellCare Dividend (HMO)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	066	0	2021	01	WellCare Guardian (HMO C-SNP)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	067	1	2021	01	WellCare Value (HMO)	Select counties in MS		Segment 1	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	067	2	2021	01	WellCare Value (HMO)	Select counties in MS		Segment 2	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	068	0	2021	01	WellCare Compass (HMO)	Select counties in MS		Select counties in MS	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	069	1	2021	02	WellCare Value (HMO-POS)	Select counties in TN		Segment 1	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	069	2	2021	02	WellCare Value (HMO-POS)	Select counties in TN		Segment 2	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1416	069	3	2021	02	WellCare Value (HMO-POS)	Select counties in TN		Segment 3	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1423	001	0	2021	01	Amerivantage Lung Care Plus (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1423	002	0	2021	01	Amerivantage Diabetes Care Plus (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1423	003	0	2021	01	Amerivantage Heart Care Plus (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1423	004	0	2021	01	Amerivantage Classic Plus (HMO)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1423	005	0	2021	01	Amerivantage Smart Value Plus (HMO)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1423	007	0	2021	01	Amerivantage CareMore Care To You Plus (HMO I-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1423	008	0	2021	01	Amerivantage CareMore Care To You Plus (HMO I-SNP)	Maricopa County		Maricopa County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H1426	001	0	2021	01	Choice (HMO)	San Joaquin County		San Joaquin County	3	0	0	18000 Studebaker Road, Suite 960		Cerritos	CA	90703				18000 Studebaker Road, Suite 960		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.VitalityHP.net	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.VitalityHP.net	www.VitalityHP.net	www.VitalityHP.net
H1426	002	0	2021	01	Choice (HMO)	Santa Clara County		Santa Clara County	3	0	0	18000 Studebaker Road, Suite 960		Cerritos	CA	90703				18000 Studebaker Road, Suite 960		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.VitalityHP.net	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.VitalityHP.net	www.VitalityHP.net	www.VitalityHP.net
H1426	003	0	2021	01	Plus (HMO)	San Joaquin and Santa Clara counties		San Joaquin and Santa Clara counties	3	0	0	18000 Studebaker Road, Suite 960		Cerritos	CA	90703				18000 Studebaker Road, Suite 960		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.VitalityHP.net	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VitalityHP.net	www.VitalityHP.net	www.VitalityHP.net
H1436	002	0	2021	01	Allwell Medicare (HMO)	Greater Charleston Area		Greater Charleston Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.absolutetotalcare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/formulary
H1436	004	0	2021	01	Allwell Medicare (HMO)	Greater Greenville/Spartanburg Area		Greater Greenville/Spartanburg Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.absolutetotalcare.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/formulary
H1436	005	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Statewide		Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	allwell.absolutetotalcare.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/formulary
H1436	801	0	2021	01	Allwell Group (HMO)	South Carolina		South Carolina	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.absolutetotalcare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/formulary
H1436	802	0	2021	01	Allwell Group (HMO)	South Carolina		South Carolina	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.absolutetotalcare.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/formulary
H1436	803	0	2021	01	Allwell Group (HMO)	South Carolina		South Carolina	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.absolutetotalcare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/findadoctor	allwell.absolutetotalcare.com/formulary
H1463	003	0	2021	01	Health Alliance Medicare HMO 20 Rx (HMO)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	008	0	2021	01	Health Alliance Medicare HMO Basic (HMO)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	009	0	2021	01	Health Alliance Medicare HMO Basic Rx (HMO)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	010	0	2021	01	Health Alliance Medicare HMO 40 Rx (HMO)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	012	0	2021	01	Reid Health Alliance Medicare HMO Rx Plus (HMO)	East Central IN and Western OH		East Central IN and Western OH	1	0	0	600 E Main Street		Richmond	IN	47374		memberservices@healthalliance.org	memberservices@healthalliance.org	600 E Main Street		Richmond	IN	47374		memberservices@healthalliance.org	memberservices@healthalliance.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	013	0	2021	01	Reid Health Alliance Medicare HMO Rx (HMO)	East Central IN and Western OH		East Central IN and Western OH	1	0	0	600 E Main Street		Richmond	IN	47374		memberservices@healthalliance.org	memberservices@healthalliance.org	600 E Main Street		Richmond	IN	47374		memberservices@healthalliance.org	memberservices@healthalliance.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	014	0	2021	02	Health Alliance Medicare POS Basic (HMO-POS)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	015	0	2021	02	Health Alliance Medicare POS Basic Rx (HMO-POS)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	017	0	2021	02	Health Alliance Medicare POS 30 Rx (HMO-POS)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	019	0	2021	02	Health Alliance Medicare POS 10 Rx (HMO-POS)	North Central, Central, Southern, & Quad Cities IL		North Central, Central, Southern, & Quad Cities IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	020	0	2021	01	Reid Health Alliance Medicare HMO (HMO)	East Central IN and Western OH		East Central IN and Western OH	1	0	0	600 E Main Street		Richmond	IN	47374		memberservices@healthalliance.org	memberservices@healthalliance.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	021	0	2021	01	Health Alliance Medicare Guide HMO Rx 2 (HMO)	Whiteside,Henry, Mercer,Rock Island IL & Scott IA		Whiteside,Henry, Mercer,Rock Island IL & Scott IA	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	022	0	2021	02	Reid Health Alliance Medicare POS Rx (HMO-POS)	East Central IN		East Central IN	1	0	0	600 E Main Street		Richmond	IN	47374		Memberservices@healthalliance.org	Memberservices@healthalliance.org	600 E Main Street		Richmond	IN	47374		Memberservices@healthalliance.org	Memberservices@healthalliance.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	023	0	2021	01	Simplete 1 (HMO)	Central IL		Central IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	024	0	2021	01	Simplete 2 (HMO)	Eastern and Central IL		Eastern and Central IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	025	0	2021	02	Simplete 3 (HMO-POS)	Eastern and Central IL		Eastern and Central IL	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	032	0	2021	01	Simplete Riverside 1 (HMO)	Kankakee and Iroquois Counties		Kankakee and Iroquois Counties	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	033	0	2021	01	Simplete Riverside 2 (HMO)	Greater Kankakee Area of NE IL/NW IN		Greater Kankakee Area of NE IL/NW IN	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	034	0	2021	02	Simplete Riverside 3 (HMO-POS)	Greater Kankakee Area of NE IL/NW IN		Greater Kankakee Area of NE IL/NW IN	1	0	0	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		Memberservices@healthalliance.org	Memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	035	0	2021	01	OSF MedAdvantage Core (HMO)	OSF		OSF	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	036	0	2021	02	OSF MedAdvantage Open (HMO-POS)	OSF		OSF	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	037	0	2021	02	OSF MedAdvantage Plus (HMO-POS)	OSF		OSF	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	038	0	2021	01	OSF MedAdvantage Select (HMO)	OSF		OSF	1	0	0	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	039	0	2021	01	Simplete Richland 1 (HMO)	Southeastern IL and Southwestern IN		Southeastern IL and Southwestern IN	1	0	0	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3000000000207002000307002000407002000507002000607002000000000000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	040	0	2021	02	Reid Health Alliance Medicare POS Rx Basic (HMO-POS)	East Central Indiana		East Central Indiana	1	0	0	600 E Main Street		Richmond	IN	47474		memberservices@healthalliance.org	memberservices@healthalliance.org	600 E Main Street		Richmond	IN	47474		memberservices@healthalliance.org	memberservices@healthalliance.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	041	0	2021	01	Reid Health Alliance Medicare HMO Basic Rx 2 (HMO)	Western OH		Western OH	1	0	0	600 E Main Street		Richmond	IN	47474		memberservices@healthalliance.org	memberservices@healthalliance.org	600 E Main Street		Richmond	IN	47474		memberservices@healthalliance.org	memberservices@healthalliance.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H1463	801	0	2021	01	Medicare Employer HMO (HMO)	Illinois		Illinois	1	3	1	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	802	0	2021	01	Medicare Employer HMO Rx (HMO)	Illinois		Illinois	1	3	1	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	810	0	2021	01	Medicare Employer HMO Rx  - non calendar year (HMO)	Illinois		Illinois	1	3	1	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	811	0	2021	02	Medicare Employer HMO-POS (HMO-POS)	Illinois		Illinois	1	3	1	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	812	0	2021	02	Medicare Employer HMO-POS with Rx (HMO-POS)	Illinois		Illinois	1	3	1	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1463	813	0	2021	02	Medicare Employer HMO-POS with Rx (HMO-POS)	Illinois		Illinois	1	3	1	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		memberservices@healthalliance.org	memberservices@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1468	007	0	2021	01	Humana Gold Plus H1468-007 (HMO)	Peoria and Rockford Illinois Metro Area		Peoria and Rockford Illinois Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	013	0	2021	01	Humana Gold Plus H1468-013 (HMO)	Cook, DuPage, Lake, and Will counties		Cook, DuPage, Lake, and Will counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	014	0	2021	01	Humana Gold Plus H1468-014 (HMO)	Kane, Kendall and McHenry counties		Kane, Kendall and McHenry counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	017	0	2021	01	Humana Community HMO Diabetes and Heart (HMO C-SNP)	Cook, DuPage and Will counties		Cook, DuPage and Will counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	018	0	2021	01	Humana Community Select HMO H1468-018 (HMO)	Chicago area		Chicago area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	019	0	2021	01	Humana Together in Health (HMO I-SNP)	Chicago Area		Chicago Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	802	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Peoria Metro area		Select counties in Peoria Metro area	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	803	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Peoria Metro area		Select counties in Peoria Metro area	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	805	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Peoria Metro area		Select counties in Peoria Metro area	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1468	806	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Peoria Metro area		Select counties in Peoria Metro area	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1500	001	0	2021	20	LIFE St. Joseph of the Pines (PACE)	LIFE St. Joseph of the Pines		LIFE St. Joseph of the Pines	1	3	0									4900 Raeford Rd		Fayetteville	NC	28304		Katie.Olsen@trinity-health.org	Katie.Olsen@trinity-health.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sjp.org	0	0	1			0					3	0	0		www.sjp.org	www.sjp.org
H1500	002	0	2021	20	LIFE St. Joseph of the Pines (PACE)	LIFE St. Joseph of the Pines		LIFE St. Joseph of the Pines	1	3	0									4900 Raeford Rd		Fayetteville	NC	28304		Katie.Olsen@trinity-health.org	Katie.Olsen@trinity-health.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sjp.org	0	0	1			0					3	0	0		www.sjp.org	www.sjp.org
H1518	001	0	2021	20	CHS Buffalo - Dual (PACE)	CHS Lackawanna  Erie County		CHS Lackawanna  Erie County	1	3	0									55 Melroy Avenue	Ground Floor	Lackawanna	NY	14218				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.chsbuffalo.org/services/pace	0	0	1			0					3	0	0		www.chsbuffalo.org	www.chsbuffalo.org
H1518	002	0	2021	20	CHS Buffalo - Medicare only (PACE)	CHS Lackawanna Erie County		CHS Lackawanna Erie County	1	3	0									55 Melroy Avenue	Ground Floor	Lackawanna	NY	14218				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.chsbuffalo.org/services/pace	0	0	1			0					3	0	0		www.chsbuffalo.org	www.chsbuffalo.org
H1533	001	0	2021	20	StayWell Senior Care - Dual Eligible (PACE)	StayWell Senior Care		StayWell Senior Care	1	3	0									809 Curry Dr.		Asheboro,	NC	27205		karen.martin@randolphhealth.org	karen.martin@randolphhealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.randolphhealth.org/services/staywell	0	0	1			0					3	0	0		www.carekinesis.com	www.staywellseniorcare.org
H1533	002	0	2021	20	StayWell Senior Care - Medicare Only (PACE)	StayWell Senior Care		StayWell Senior Care	1	3	0									809 Curry Dr.		Asheboro,	NC	27205		karen.martin@randolphhealth.org	karen.martin@randolphhealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.randolphhealth.org/services/staywell	0	0	1			0					3	0	0		www.carekinesis.com	www.staywellseniorcare.org
H1537	005	0	2021	04	UnitedHealthcare Medicare Advantage Choice (PPO)	Hamilton County		Hamilton County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	801	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	802	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	803	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	804	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	805	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	806	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	807	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	NY and Select Counties		NY and Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	808	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	NY and Select Counties		NY and Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	809	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	NY and Select Counties		NY and Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	816	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	NY and Select Counties		NY and Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	817	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	NY and Select Counties		NY and Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	823	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	824	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	825	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	826	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	827	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	828	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	829	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	830	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	831	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	832	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	833	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	834	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	835	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	836	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	837	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	838	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	839	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	840	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	841	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1537	842	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1544	001	0	2021	20	LA Coast PACE (PACE)	Parts of Los Angeles County		Parts of Los Angeles County	1	3	0									1220 E 4th Street		Long Beach	CA	90802				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lacoastpace.welbehealth.com	0	0	1			0					3	0	0		TBD	NA
H1544	002	0	2021	20	LA Coast PACE (PACE)	Parts of Los Angeles County		Parts of Los Angeles County	1	3	0									1220 E 4th Street		Long Beach	CA	90802				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lacoastpace.welbehealth.com	0	0	1			0					3	0	0		TBD	NA
H1587	001	0	2021	02	Tribute Advantage (HMO-POS D-SNP)	Arkansas		Arkansas	1	0	0	1 Riverfront Place	Suite 615	North Little Rock	AR	72114		info@superiorselectinc.com	info@superiorselectinc.com	1 Riverfront Place	Suite 615	North Little Rock	AR	72114		info@superiorselectinc.com	info@superiorselectinc.com	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.superiorselectmedicare.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.superiorselectmedicare.com	www.superiorselectmedicare.com	www.superiorselectmedicare.com
H1587	003	0	2021	02	Tribute Select (HMO-POS I-SNP)	Arkansas		Arkansas	1	0	0	1 Riverfront Place	Suite 615	North Little Rock	AR	72114		info@superiorselectinc.com	info@superiorselectinc.com	1 Riverfront Place	Suite 615	North Little Rock	AR	72114		info@superiorselectinc.com	info@superiorselectinc.com	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.superiorselectmedicare.com	1	1	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.superiorselectmedicare.com	www.superiorselectmedicare.com	www.superiorselectmedicare.com
H1607	012	0	2021	04	Anthem MediBlue Access Plus (PPO)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $60.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $60.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1607	014	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1607	015	0	2021	04	Anthem MediBlue Access Preferred (PPO)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1607	809	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	810	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	811	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	812	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	813	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	814	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	815	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	816	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	817	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	818	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	819	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1607	820	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H1608	001	0	2021	04	Aetna Medicare Premier (PPO)	Partial State of Iowa and South Dakota		Partial State of Iowa and South Dakota	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	004	0	2021	04	Aetna Medicare Prime (PPO)	Lincoln, McCook, Minnehaha Counties		Lincoln, McCook, Minnehaha Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	007	0	2021	04	Aetna Medicare Prime (PPO)	Marshall and Story Counties		Marshall and Story Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	008	0	2021	04	Aetna Medicare Prime (PPO)	Ida, Monona, Plymouth, Woodbury Counties		Ida, Monona, Plymouth, Woodbury Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	012	0	2021	04	Aetna Medicare Premier (PPO)	Partial State of Nebraska		Partial State of Nebraska	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	013	0	2021	04	Aetna Medicare Premier Advantra (PPO)	St Louis Metro		St Louis Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	016	0	2021	04	Aetna Medicare Premier Plus (PPO)	KC Metro Kansas & Missouri Counties		KC Metro Kansas & Missouri Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	017	0	2021	04	Aetna Medicare Premier Plus (PPO)	Wichita Metro Counties		Wichita Metro Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	018	0	2021	04	Aetna Medicare Premier Plus (PPO)	Southwest Missouri, Southeast Kansas		Southwest Missouri, Southeast Kansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	021	0	2021	04	Aetna Medicare Premier Plus (PPO)	Northwest Arkansas Area		Northwest Arkansas Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	024	0	2021	04	Aetna Medicare Premier Plus 2 (PPO)	Northeast Topeka Area		Northeast Topeka Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	026	0	2021	04	Aetna Medicare Advantra Gold (PPO)	Northern West Virginia		Northern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	027	0	2021	04	Aetna Medicare Advantra Gold (PPO)	Southern West Virginia		Southern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	028	0	2021	04	Aetna Medicare Advantra Preferred Plan (PPO)	Select Counties in Atlanta and Savannah Markets		Select Counties in Atlanta and Savannah Markets	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	029	0	2021	04	Aetna Medicare Advantra Silver (PPO)	Northeastern and Youngstown Area		Northeastern and Youngstown Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	031	0	2021	04	Aetna Medicare Advantra Credit Value (PPO)	West Virginia		West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	035	0	2021	04	Aetna Medicare Premier Advantra (PPO)	Hannibal Missouri		Hannibal Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	037	0	2021	04	Aetna Medicare Elite (PPO)	Partial State of Iowa		Partial State of Iowa	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	038	0	2021	04	Aetna Medicare Elite (PPO)	Partial State of Nebraska		Partial State of Nebraska	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	039	0	2021	04	Aetna Medicare Elite (PPO)	Western Missouri and Eastern Kansas		Western Missouri and Eastern Kansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	040	0	2021	04	Aetna Medicare Advantra Value (PPO)	Southern West Virginia		Southern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	041	0	2021	04	Aetna Medicare Advantra Value (PPO)	Northern West Virginia		Northern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	043	0	2021	04	Aetna Medicare Elite (PPO)	Partial State of South Dakota		Partial State of South Dakota	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	047	0	2021	04	Aetna Medicare Elite (PPO)	Southwest Missouri, Southeast Kansas		Southwest Missouri, Southeast Kansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	048	0	2021	04	Aetna Medicare Premier Plus (PPO)	Central Iowa		Central Iowa	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	050	0	2021	04	Aetna Medicare Elite (PPO)	St Louis Metro		St Louis Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	051	0	2021	04	Aetna Medicare Premier Plus (PPO)	Cape Girardeau MO		Cape Girardeau MO	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	052	0	2021	04	Aetna Medicare Elite (PPO)	Northwest Missouri		Northwest Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	053	0	2021	04	Aetna Medicare Elite (PPO)	Wichita Metro		Wichita Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	054	0	2021	04	Aetna Medicare Elite (PPO)	Northwest Arkansas		Northwest Arkansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	055	0	2021	04	Aetna Medicare Elite (PPO)	Central Missouri		Central Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	056	0	2021	04	Aetna Medicare Premier Plus (PPO)	Southwest Illinois		Southwest Illinois	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	059	0	2021	04	Aetna Medicare Elite (PPO)	Topeka and Surrounding Counties		Topeka and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	060	0	2021	04	Aetna Medicare Eagle (PPO)	St Louis Metro Area		St Louis Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	801	0	2021	04	Aetna Medicare Plan (PPO)	Multi-State		Multi-State	1	3	1	151 Farmington Ave		Hartford	CT	06156		SchulzF@Aetna.com										9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1608	802	0	2021	04	Aetna Medicare Plan w/Rx (PPO)	Multi-Plan		Multi-Plan	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	001	0	2021	01	Aetna Medicare Premier (HMO)	Partial State of Iowa		Partial State of Iowa	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	009	0	2021	01	Aetna Medicare Prime (HMO)	Dallas, Polk, Warren Counties		Dallas, Polk, Warren Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	016	0	2021	01	Aetna Medicare Select (HMO)	South FL		South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	017	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	South FL		South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	018	0	2021	01	Aetna Medicare Select (HMO)	South FL		South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	019	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	South FL, Treasure Coast FL, West FL		South FL, Treasure Coast FL, West FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	020	0	2021	01	Aetna Medicare Select (HMO)	South FL		South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	021	0	2021	01	Aetna Medicare Select (HMO)	North FL, Treasure Coast FL		North FL, Treasure Coast FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	022	0	2021	01	Aetna Medicare Select (HMO)	West FL		West FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	023	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Central FL		Central FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	025	0	2021	01	Aetna Medicare Select (HMO)	Southwest FL		Southwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	026	0	2021	01	Aetna Medicare Value (HMO)	Southwest FL		Southwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	027	0	2021	01	Aetna Medicare Select (HMO)	Southwest FL		Southwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	028	0	2021	02	Aetna Medicare Choice (HMO-POS)	North, Central, West, SW, Treasure Coast, South FL		North, Central, West, SW, Treasure Coast, South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	034	0	2021	01	Aetna Medicare Select (HMO)	West FL, Treasure Coast FL		West FL, Treasure Coast FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	035	0	2021	01	Aetna Medicare Select (HMO)	Southwest FL		Southwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	037	0	2021	01	Aetna Medicare Select (HMO)	Central FL		Central FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	038	0	2021	01	Aetna Medicare Select (HMO)	West FL		West FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	039	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	North FL		North FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	040	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Southwest FL		Southwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	041	0	2021	01	Aetna Medicare Select (HMO)	Panhandle/Northwest FL		Panhandle/Northwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	042	0	2021	01	Aetna Medicare Select (HMO)	Central FL		Central FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	043	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	South FL		South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	044	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	West FL		West FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	045	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	North FL, Treasure Coast FL		North FL, Treasure Coast FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	046	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	Central FL		Central FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	047	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	Southwest FL		Southwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	048	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	Palm Beach		Palm Beach	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	049	0	2021	01	Aetna Medicare Assure Plus (HMO D-SNP)	West FL		West FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	052	0	2021	01	Aetna Medicare Eagle (HMO)	Panhandle/Northwest FL		Panhandle/Northwest FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	053	0	2021	01	Aetna Medicare Credit (HMO)	South FL		South FL	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	801	0	2021	01	Aetna Medicare Plan (HMO)	Florida		Florida	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1609	807	0	2021	01	Aetna Medicare w/Rx Plan (HMO)	Florida		Florida	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1610	001	0	2021	01	Aetna Better Health of Virginia (HMO D-SNP)	Virginia		Virginia	1	0	0	7400 W Campus Rd		New Albany	OH	43054		VA_DSNP_MemberServices@aetna.com	VA_DSNP_MemberServices@aetna.com	7400 W Campus Rd		New Albany	OH	43054		VA_DSNP_MemberServices@aetna.com	VA_DSNP_MemberServices@aetna.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnabetterhealth.com/virginia-hmosnp	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnabetterhealth.com/virginia-hmosnp/findprovider	www.aetnabetterhealth.com/virginia-hmosnp/findpharmacy	www.aetnabetterhealth.com/Virginia-hmosnp/formulary
H1622	001	0	2021	20	NEMS PACE (PACE)	San Francisco County		San Francisco County	1	3	0									728 Pacific Avenue	Suite 200	San Francisco	CA	94133		sharon.raver@nems.org	sharon.raver@nems.org	5000000000208301730308301730408301730508301730608301730000000000	5000000000208301730308301730408301730508301730608301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.nems.org/pace/	0	0	1			0					3	0	0		N/A	N/A
H1622	003	0	2021	20	NEMS PACE – Medicare Only (PACE)	San Francisco County		San Francisco County	1	3	0									728 Pacific Avenue	Suite 200	San Francisco	CA	94133		sharon.raver@nems.org	sharon.raver@nems.org	5000000000208301730308301730408301730508301730608301730000000000	5000000000208302030308302030408302030508302030608302030000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.nems.org/pace/	0	0	1			0					3	0	0		N/A	N/A
H1644	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	Florida (partial)		Florida (partial)	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H1651	001	0	2021	18	Medical Associates SmartPlan (Cost)	Dubuque, Clayton, Delaware, Jackson,Jones Counties		Dubuque, Clayton, Delaware, Jackson,Jones Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		memberservices@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	002	0	2021	18	Medical Associates Basic Plan (Cost)	Dubuque, Clayton, Delaware, Jackson,Jones Counties		Dubuque, Clayton, Delaware, Jackson,Jones Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	003	0	2021	18	Medical Associates SmartPlan (Cost)	JoDaviess County		JoDaviess County	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	004	0	2021	18	Medical Associates Community Plan (Cost)	Dubuque, Clayton, Delaware, Jackson,Jones Counties		Dubuque, Clayton, Delaware, Jackson,Jones Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	005	0	2021	18	Medical Associates Community Plan (Cost)	JoDaviess County		JoDaviess County	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	008	0	2021	18	Medical Associates Freedom Plan (Cost)	Dubuque, Clayton, Delaware, Jackson,Jones Counties		Dubuque, Clayton, Delaware, Jackson,Jones Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	009	0	2021	18	Medical Associates Freedom Plan (Cost)	JoDaviess County		JoDaviess County	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	010	0	2021	18	MercyOne Cedar Valley Senior Plan (Cost)	Cedar Valley		Cedar Valley	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	011	0	2021	18	Central Iowa Health Senior Plan (Cost)	Central Iowa		Central Iowa	1	0	0	1605 Associates Drive		Dubuque	IA	52002		mhager@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	012	0	2021	18	MercyOne Clinton Community Senior Plan (Cost)	Clinton, Scott, Jackson, Cedar Counties		Clinton, Scott, Jackson, Cedar Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	013	0	2021	18	Quad Cities Community Health Senior Plan (Cost)	Clinton, Scott, Jackson, Cedar, Muscatine Counties		Clinton, Scott, Jackson, Cedar, Muscatine Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		mlansing@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	014	0	2021	18	Mercy Cedar Rapids Senior Plan (Cost)	Cedar Rapids and Surrounding Counties		Cedar Rapids and Surrounding Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		mlansing@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	015	0	2021	18	MercyOne North Iowa Senior Plan (Cost)	North Iowa		North Iowa	1	0	0	1605 Associates Drive		Dubuque	IA	52002		mhager@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	016	0	2021	18	Mercy Iowa City Senior Plan (Cost)	Iowa, Johnson, Cedar Washington Muscatine Counties		Iowa, Johnson, Cedar Washington Muscatine Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		mlansing@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	017	0	2021	18	Quad Cities Community Health Senior Plan (Cost)	Rock Island and Mercer Counties		Rock Island and Mercer Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	025	0	2021	18	Live360 Health Plan (Cost)	South Central Illinois		South Central Illinois	1	0	0	1605 Associates Drive		Dubuque	IA	52002		live360healthplan@mahealthcare.com	live360healthplan@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.live360healthplan.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1651	026	0	2021	18	Medical Associates Nebraska Senior Plan (Cost)	Southeast Nebraska		Southeast Nebraska	1	0	0	1605 Associates Drive		Dubuque	IA	52002												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H1659	002	0	2021	04	UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO)	City: LYH Counties: AM,AP,BE,CA,CLT,HA,PE,PI		City: LYH Counties: AM,AP,BE,CA,CLT,HA,PE,PI	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	myUHCPiedmont.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $405.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $405.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1659	003	0	2021	04	UnitedHealthcare Medicare Advantage Choice Plan 2 (PPO)	City: LYH Counties: AM,AP,BE,CA,CLT,HA,PE,PI		City: LYH Counties: AM,AP,BE,CA,CLT,HA,PE,PI	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	myUHCPiedmont.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $405.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $405.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1660	013	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Maine		Maine	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	014	0	2021	01	Harvard Pilgrim Stride Basic Rx (HMO)	Massachusetts		Massachusetts	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	015	0	2021	01	Harvard Pilgrim Stride Basic Rx (HMO)	Maine		Maine	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	016	1	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Massachusetts		Worcester County MA	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	016	2	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Massachusetts		Eastern Massachusetts	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	017	1	2021	01	Harvard Pilgrim Stride Value Rx Plus (HMO)	Massachusetts		Worcester County MA	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	017	2	2021	01	Harvard Pilgrim Stride Value Rx Plus (HMO)	Massachusetts		Eastern Massachusetts	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	018	0	2021	02	Harvard Pilgrim Stride Choice Rx (HMO-POS)	Maine		Maine	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	802	0	2021	02	Harvard Pilgrim Stride Choice Rx (HMO-POS)	Maine		Maine	1	3	1	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	803	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Massachusetts		Massachusetts	1	3	1	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1660	804	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Maine		Maine	1	3	1	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H1664	001	0	2021	01	Allwell Medicare (HMO)	SW, Eastern Missouri and St Louis Metro Areas		SW, Eastern Missouri and St Louis Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	002	0	2021	01	Allwell Medicare (HMO)	Cass, Clay, Jackson, Platte		Cass, Clay, Jackson, Platte	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	004	0	2021	01	Allwell Medicare (HMO)	SW, Eastern Missouri and St Louis Metro Areas		SW, Eastern Missouri and St Louis Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	005	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	West and South Missouri Counties		West and South Missouri Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	006	0	2021	01	Allwell Medicare Boost (HMO)	SW, Eastern Missouri and St Louis Metro Areas		SW, Eastern Missouri and St Louis Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	007	0	2021	01	Allwell Medicare Complement (HMO)	SW, Eastern Missouri and St Louis Metro Areas		SW, Eastern Missouri and St Louis Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	008	0	2021	01	Allwell Medicare Boost (HMO)	Cass, Clay, Jackson, Platte		Cass, Clay, Jackson, Platte	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	009	0	2021	01	Allwell Medicare Complement (HMO)	Cass, Clay, Jackson, Platte		Cass, Clay, Jackson, Platte	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	010	0	2021	01	Allwell Medicare Boost (HMO)	SW, Eastern Missouri and St Louis Metro Areas		SW, Eastern Missouri and St Louis Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	011	0	2021	01	Allwell Medicare Complement (HMO)	SW, Eastern Missouri and St Louis Metro Areas		SW, Eastern Missouri and St Louis Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com
H1664	801	0	2021	01	Allwell Group (HMO)	Missouri		Missouri	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	802	0	2021	01	Allwell Group (HMO)	Missouri		Missouri	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1664	803	0	2021	01	Allwell Group (HMO)	Missouri		Missouri	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.homestatehealth.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/findadoctor	allwell.homestatehealth.com/formulary
H1666	001	0	2021	04	Blue Cross Medicare Advantage Choice Premier (PPO)	Austin Metro Area		Austin Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	002	0	2021	04	Blue Cross Medicare Advantage Choice Premier (PPO)	Dallas Metro Area		Dallas Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	003	0	2021	04	Blue Cross Medicare Advantage Choice Premier (PPO)	Houston Metro Area		Houston Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	004	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	Austin Metro Area		Austin Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	005	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	Dallas Metro Area		Dallas Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	006	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	Houston Metro Area		Houston Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	008	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	San Antonio Metro Area		San Antonio Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	010	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	El Paso		El Paso	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	801	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Texas		State of Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	803	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Texas		State of Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	805	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Texas		State of Texas	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	807	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Texas		State of Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1666	808	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Texas		State of Texas	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H1692	002	0	2021	01	Aetna Medicare Advantra Silver (HMO)	Southern West Virginia		Southern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1692	003	0	2021	01	Aetna Medicare Advantra Elite (HMO)	Northern West Virginia		Northern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1692	004	0	2021	01	Aetna Medicare Advantra Elite (HMO)	Southern West Virginia		Southern West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1692	005	0	2021	01	Aetna Medicare Advantra Cares (HMO D-SNP)	West Virginia		West Virginia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1692	801	0	2021	01	Aetna Medicare Plan (HMO)	West Virginia		West Virginia	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1692	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	West Virginia		West Virginia	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H1693	002	0	2021	20	FamilyHealth - Center for Older Adults (PACE)	San Diego		San Diego	1	3	0									3420 College Ave		San Diego	CA	92115		PACEcontracts@fhcsd.org	PACEcontracts@fhcsd.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fhcsd.org/pace	0	0	1			0					3	0	0		TBD	NA
H1693	003	0	2021	20	FamilyHealth-Center for Older Adults-Medicare-only (PACE)	San Diego		San Diego	1	3	0									3420 College Avenue		San Diego	CA	92115		PACEcontracts@fhcsd.org	PACEcontracts@fhcsd.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fhcsd.org/pace	0	0	1			0					3	0	0		TBD	NA
H1714	001	0	2021	20	Ascension Living HOPE (PACE)	Sedgwick County	Ascension Living HOPE (PACE)	Sedgwick County	1	3	0									2622 W. Central Ave, Suite 101		Wichita	KS	67203				3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	ascension.org/HOPEKansas	0	0	1			0					3	0	0		www.viachristihope.com	www.viachristihope.com
H1714	002	0	2021	20	Ascension Living HOPE (PACE)	Sedgwick County	Ascension Living HOPE (PACE)	Sedgwick County	1	3	0									2622 W. Central Ave, Suite 101		Wichita	KS	67203				3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	ascension.org/HOPEKansas	0	0	1			0					3	0	0		www.viachristihope.com	www.viachristihope.com
H1722	002	0	2021	01	Healthfirst Signature (HMO)	Westchester County	Signature de Healthfirst (HMO)	Westchester County	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H1723	001	0	2021	48	Absolute Total Care (Medicare-Medicaid Plan)	SC - 41 of 46 counties		SC - 41 of 46 counties	1	0	0	PO Box 2020		Farmington	MO	63640				PO Box 2020		Farmington	MO	63640				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	mmp.absolutetotalcare.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	mmp.absolutetotalcare.com/findadoctor	mmp.absolutetotalcare.com/findadoctor	mmp.absolutetotalcare.com/formulary
H1732	001	0	2021	01	Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)	Select Counties in NY		Select Counties in NY	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1732	002	0	2021	01	Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)	Select Counties in NY		Select Counties in NY	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1732	003	0	2021	01	Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)	Select Counties in NY		Select Counties in NY	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1732	004	0	2021	01	Empire MediBlue HealthPlus (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1732	005	0	2021	01	Empire MediBlue HealthPlus (HMO)	Orange, Rockland, Westchester Counties		Orange, Rockland, Westchester Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1732	006	0	2021	01	Empire MediBlue HealthPlus (HMO)	Nassau and Suffolk Counties		Nassau and Suffolk Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1737	001	0	2021	01	Health Alliance Medicare Guide HMO Rx (HMO)	Scott County		Scott County	1	0	0	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1737	801	0	2021	01	Medicare Employer HMO (HMO)	Health Alliance Medicare		Health Alliance Medicare	1	3	1	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1737	802	0	2021	01	Medicare Employer HMO Rx (HMO)	Health Alliance Medicare		Health Alliance Medicare	1	3	1	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1737	803	0	2021	01	Medicare Employer HMO Rx  - non calendar year (HMO)	Health Alliance Medicare		Health Alliance Medicare	1	3	1	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H1748	001	0	2021	01	Sonder Health Plans, Inc. (HMO)	Fulton, DeKalb, Cobb, Gwinnett Counties		Fulton, DeKalb, Cobb, Gwinnett Counties	1	0	0	100 Hartsfield Centre Pkwy	Suite 500	Atlanta	GA	30354		memberservices@sonderhealthplans.com	memberservices@sonderhealthplans.com	100 Hartsfield Centre Pkwy	Suite 500	Atlanta	GA	30354		memberservices@sonderhealthplans.com	memberservices@sonderhealthplans.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sonderhealthplans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.sonderhealthplans.com	www.sonderhealthplans.com	www.sonderhealthplans.com
H1748	003	0	2021	01	Sonder Health Plans, Inc. (HMO C-SNP)	Fulton, DeKalb, Cobb, Gwinnett Counties		Fulton, DeKalb, Cobb, Gwinnett Counties	1	0	0	100 Hartsfield Centre Pkwy	Suite 500	Atlanta	GA	30354		memberservices@sonderhealthplans.com	memberservices@sonderhealthplans.com	100 Hartsfield Centre Pkwy	Suite 500	Atlanta	GA	30354		memberservices@sonderhealthplans.com	memberservices@sonderhealthplans.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sonderhealthplans.com	1	4	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.sonderhealthplans.com	www.sonderhealthplans.com	www.sonderhealthplans.com
H1748	004	0	2021	01	Sonder Health Plans, Inc. (HMO C-SNP)	Fulton, DeKalb, Cobb, Gwinnett Counties		Fulton, DeKalb, Cobb, Gwinnett Counties	1	0	0	100 Hartsfield Centre Pkwy	Suite 500	Atlanta	GA	30354		memberservices@sonderhealthplans.com	memberservices@sonderhealthplans.com	100 Hartsfield Centre Pkwy	Suite 500	Atlanta	GA	30354		memberservices@sonderhealthplans.com	memberservices@sonderhealthplans.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sonderhealthplans.com	1	4	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.sonderhealthplans.com	www.sonderhealthplans.com	www.sonderhealthplans.com
H1774	001	0	2021	04	Ascension Complete St. Vincent Access (PPO)	Central, Southeast and Southwest Indiana Counties		Central, Southeast and Southwest Indiana Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ascensioncomplete.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ascensioncomplete.com/in-findadoctor	www.ascensioncomplete.com/in-findadoctor	www.ascensioncomplete.com/in-formulary
H1777	007	0	2021	01	ArchCare  Advantage (HMO I-SNP)	NYC, Westchester, Putnam, Dutchess, Orange, Ononda	ArchCare Advantage (HMO I-SNP)	NYC, Westchester, Putnam, Dutchess, Orange, Ononda	1	0	0	205 Lexington Avenue	2nd Floor	NEW YORK	NY	10016				205 Lexington Avenue	2nd Floor	NEW YORK	NY	10016				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.archcareadvantage.org	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.archcareadvantage.org	www.archcareadvantage.org	www.archcareadvantage.org
H1787	001	0	2021	01	Great Plains Medicare Advantage (HMO I-SNP)	South Dakota (partial)		South Dakota (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.greatplainsmedicareadvantage.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com
H1787	002	0	2021	01	Great Plain Medicare Advantage Gold (HMO I-SNP)	South Dakota (partial)		South Dakota (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.greatplainsmedicareadvantage.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com
H1821	001	0	2021	04	AARP Medicare Advantage Choice (PPO)	Spokane county		Spokane county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1821	002	0	2021	04	AARP Medicare Advantage Choice (PPO)	Clark, Cowlitz, Island, King, Snohomish, Thurston		Clark, Cowlitz, Island, King, Snohomish, Thurston	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1821	003	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in Oregon		Select Counties in Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1846	004	0	2021	04	MediGold Flexible Choice (PPO)	Select Ohio Counties		Select Ohio Counties	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H1846	801	0	2021	04	EGWP MediGold Network Choice (PPO)	Greater Central Ohio and Dayton Area		Greater Central Ohio and Dayton Area	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H1846	802	0	2021	04	EGWP MediGold Network Choice Medical Only (PPO)	Greater Central Ohio and Dayton Area		Greater Central Ohio and Dayton Area	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H1848	001	0	2021	04	WellCare Absolute (PPO)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1848	002	0	2021	04	WellCare Premier (PPO)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1862	001	0	2021	01	WellCare Value (HMO)	Select counties in VT		Select counties in VT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1889	002	1	2021	04	UnitedHealthcare Dual Complete Choice (PPO D-SNP)	Select Counties in Florida		Northern Florida	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H1889	002	2	2021	04	UnitedHealthcare Dual Complete Choice (PPO D-SNP)	Select Counties in Florida		Southern Florida	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H1894	001	0	2021	01	Amerivantage Classic (HMO)	Select counties in Washington	Amerivantage Classic (HMO)	Select counties in Washington	1	0	0	Amerigroup Washington	705 Union Station, Suite 300 - 705 Fifth Avenue South	Seattle	WA	98104				Amerigroup Washington	705 Union Station, Suite 300 - 705 Fifth Avenue South	Seattle	WA	98104				9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H1894	002	0	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select counties in Washington	Amerivantage Dual Coordination (HMO D-SNP)	Select counties in Washington	1	0	0	Amerigroup Washington	705 Union Station, Suite 300 - 705 Fifth Avenue South	Seattle	WA	98104				Amerigroup Washington	705 Union Station, Suite 300 - 705 Fifth Avenue South	Seattle	WA	98104				9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H1904	001	0	2021	20	PACE Greater New Orleans (PACE)	PACE Greater New Orleans		PACE Greater New Orleans	1	3	0									4201 N RAMPART STREET		NEW ORLEANS	LA	70117		pace@ccano.org	pace@ccano.org	3100000000200000000300000000400000000500000000600000000700000000	3108002000200000000300000000400000000500000000600000000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://pacegno.org/	0	0	1			0					3	0	0		http://www.pacegno.org	http://www.pacegno.org
H1904	002	0	2021	20	PACE Greater New Orleans (PACE)	PACE Greater New Orleans		PACE Greater New Orleans	1	3	0									4201 N RAMPART ST		NEW ORLEANS	LA	70117		pace@ccano.org	pace@ccano.org	3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://pacegno.org/	0	0	1			0					3	0	0		http://www.pacegno.org	http://www.pacegno.org
H1914	001	0	2021	04	WellCare Premier (PPO)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1914	002	0	2021	04	WellCare Absolute (PPO)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1914	003	0	2021	04	WellCare Endurance (PPO)	All counties in CT		All counties in CT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H1924	001	0	2021	07	Lasso Healthcare Growth (MSA)	Lasso Healthcare Growth		Lasso Healthcare Growth	1	3	0	P.O. Box 261113		Plano	TX	75026		info@lassohealthcare.com	info@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	004	0	2021	07	Lasso Healthcare Growth Plus (MSA)	Lasso Healthcare Growth Plus		Lasso Healthcare Growth Plus	1	3	0	P.O. Box 261113		Plano	TX	75026		info@lassohealthcare.com	info@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	803	0	2021	07	Lasso Healthcare Employer Group 200 (MSA)	Lasso Healthcare Employer Group 200		Lasso Healthcare Employer Group 200	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	804	0	2021	07	Lasso Healthcare Employer Group 220 (MSA)	Lasso Healthcare Employer Group 220		Lasso Healthcare Employer Group 220	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	805	0	2021	07	Lasso Healthcare Employer Group 250 (MSA)	Lasso Healthcare Employer Group 250		Lasso Healthcare Employer Group 250	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	806	0	2021	07	Lasso Healthcare Employer Group 270 (MSA)	Lasso Healthcare Employer Group 270		Lasso Healthcare Employer Group 270	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	807	0	2021	07	Lasso Healthcare Employer Group 300 (MSA)	Lasso Healthcare Employer Group 300		Lasso Healthcare Employer Group 300	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	808	0	2021	07	Lasso Healthcare Employer Group 50 (MSA)	Lasso Healthcare Employer Group 50		Lasso Healthcare Employer Group 50	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	809	0	2021	07	Lasso Healthcare Employer Group 67 (MSA)	Lasso Healthcare Employer Group 67		Lasso Healthcare Employer Group 67	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	810	0	2021	07	Lasso Healthcare Employer Group 83 (MSA)	Lasso Healthcare Employer Group 83		Lasso Healthcare Employer Group 83	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	811	0	2021	07	Lasso Healthcare Employer Group 100 (MSA)	Lasso Healthcare Employer Group 100		Lasso Healthcare Employer Group 100	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	812	0	2021	07	Lasso Healthcare Employer Group 117 (MSA)	Lasso Healthcare Employer Group 117		Lasso Healthcare Employer Group 117	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	813	0	2021	07	Lasso Healthcare Employer Group 133 (MSA)	Lasso Healthcare Employer Group 133		Lasso Healthcare Employer Group 133	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	814	0	2021	07	Lasso Healthcare Employer Group 150 (MSA)	Lasso Healthcare Employer Group 150		Lasso Healthcare Employer Group 150	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	815	0	2021	07	Lasso Healthcare Employer Group 167 (MSA)	Lasso Healthcare Employer Group 167		Lasso Healthcare Employer Group 167	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1924	816	0	2021	07	Lasso Healthcare Employer Group 183 (MSA)	Lasso Healthcare Employer Group 183		Lasso Healthcare Employer Group 183	1	3	1	P.O. Box 261113		Plano	TX	75026		groupmsa@lassohealthcare.com	groupmsa@lassohealthcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	lassohealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H1944	001	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Middlesex and Suffolk counties		Middlesex and Suffolk counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	004	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Middlesex and Suffolk counties		Middlesex and Suffolk counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	005	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select Counties in Massachusetts		Select Counties in Massachusetts	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	006	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select Counties in Massachusetts		Select Counties in Massachusetts	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	009	0	2021	01	AARP Medicare Advantage (HMO)	Select Counties in Pennsylvania		Select Counties in Pennsylvania	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	010	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	West Pennsylvania		West Pennsylvania	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	011	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	West Pennsylvania		West Pennsylvania	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	014	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	015	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	016	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	017	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select counties in New Hampshire		Select counties in New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	018	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select counties in Vermont		Select counties in Vermont	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	024	0	2021	01	AARP Medicare Advantage (HMO)	Philadelphia Metro Area		Philadelphia Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	028	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select Counties in Vermont		Select Counties in Vermont	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	030	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select Counties in Pennsylvania		Select Counties in Pennsylvania	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	031	0	2021	01	AARP Medicare Advantage Plan 4 (HMO)	Select counties in New Hampshire		Select counties in New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	032	0	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Select counties in Vermont		Select counties in Vermont	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H1944	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in MA, NH, PA, RI, VT		Select counties in MA, NH, PA, RI, VT	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1944	806	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in MA, NH, PA, RI, VT		Select counties in MA, NH, PA, RI, VT	1	3	1	PO Box 29675		Hot Springs	AR	71903												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1944	807	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in MA, NH, PA, RI, VT		Select counties in MA, NH, PA, RI, VT	1	3	1	PO Box 29675		Hot Springs	AR	71903				PO Box 29675		Hot Springs	AR	71903				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H1947	001	0	2021	01	Healthy Blue Dual Advantage (HMO D-SNP)	Select Parishes in Louisiana		Select Parishes in Louisiana	1	0	0	1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206				1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.healthybluela.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	shop.healthybluela.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H1951	013	0	2021	01	Humana Gold Plus H1951-013 (HMO)	Shreveport Area		Shreveport Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	024	0	2021	01	Humana Gold Plus H1951-024 (HMO)	Tangipahoa Parish		Tangipahoa Parish	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	028	0	2021	01	Humana Gold Plus H1951-028 (HMO)	Washington and St. Tammany Parishes		Washington and St. Tammany Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	032	0	2021	01	Humana Gold Plus SNP-DE H1951-032 (HMO D-SNP)	Baton Rouge Area		Baton Rouge Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	033	0	2021	01	Humana Gold Plus SNP-DE H1951-033 (HMO D-SNP)	New Orleans Area		New Orleans Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	034	0	2021	01	Humana Gold Plus SNP-DE H1951-034 (HMO D-SNP)	Washington and St. Tammany Parishes		Washington and St. Tammany Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	038	0	2021	01	Humana-Ochsner Network H1951-038 (HMO)	New Orleans Area		New Orleans Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	039	0	2021	01	Humana-Ochsner Network H1951-039 (HMO)	Baton Rouge Area		Baton Rouge Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	041	0	2021	01	Humana Gold Plus SNP-DE H1951-041 (HMO D-SNP)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	044	0	2021	01	Humana Gold Plus - Diabetes and Heart H1951-044 (HMO C-SNP)	Jefferson and Orleans Parishes		Jefferson and Orleans Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	047	1	2021	01	Humana Gold Plus H1951-047 (HMO)	New Orleans Area		New Orleans Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	047	2	2021	01	Humana Gold Plus H1951-047 (HMO)	New Orleans Area		New Orleans Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	048	1	2021	01	Humana Gold Plus H1951-048 (HMO)	Baton Rouge Area		Baton Rouge Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	048	2	2021	01	Humana Gold Plus H1951-048 (HMO)	Baton Rouge Area		Baton Rouge Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	049	1	2021	01	Humana Gold Plus H1951-049 (HMO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	049	2	2021	01	Humana Gold Plus H1951-049 (HMO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	049	3	2021	01	Humana Gold Plus H1951-049 (HMO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	051	0	2021	01	Humana LCMC Advantage H1951-051 (HMO)	New Orleans Area		New Orleans Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	052	0	2021	01	Humana Gold Plus H1951-052 (HMO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	801	0	2021	01	Humana Medicare Employer (HMO)	Select parishes in Louisiana		Select parishes in Louisiana	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	804	0	2021	01	Humana Medicare Employer (HMO)	Select parishes in Louisiana		Select parishes in Louisiana	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	807	0	2021	01	Humana Medicare Employer (HMO)	Select parishes in Louisiana		Select parishes in Louisiana	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1951	808	0	2021	01	Humana Medicare Employer (HMO)	Select parishes in Louisiana		Select parishes in Louisiana	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H1961	003	0	2021	01	Peoples Health Secure Health (HMO D-SNP)	South Louisiana		South Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	011	0	2021	01	Peoples Health Secure Choice (HMO D-SNP)	North and Central Louisiana		North and Central Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	014	1	2021	01	Peoples Health Choices 65 (HMO)	New Orleans Metro Area and Northshore		Orleans, Jefferson and East Baton Rouge Parish	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	014	2	2021	01	Peoples Health Choices 65 (HMO)	New Orleans Metro Area and Northshore		Northshore	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	014	3	2021	01	Peoples Health Choices 65 (HMO)	New Orleans Metro Area and Northshore		Southland	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	014	4	2021	01	Peoples Health Choices 65 (HMO)	New Orleans Metro Area and Northshore		Rural Southeast	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	017	0	2021	01	Peoples Health Choices Gold (HMO)	Southwest and North Louisiana		Southwest and North Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	018	0	2021	01	Peoples Health Choices Value (HMO)	Southwest and North Louisiana		Southwest and North Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	019	0	2021	01	Peoples Health Secure Complete (HMO D-SNP)	Louisiana		Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	801	0	2021	02	Peoples Health Group Medicare (HMO-POS)	Nationwide		Nationwide	1	3	1	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	802	0	2021	02	Peoples Health Group Medicare (HMO-POS)	Nationwide		Nationwide	1	3	1	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	803	0	2021	01	Peoples Health Group Medicare (HMO)	Nationwide		Nationwide	1	3	1	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1961	804	0	2021	01	Peoples Health Group Medicare (HMO)	Nationwide		Nationwide	1	3	1	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H1969	002	0	2021	01	Regence Blue MedAdvantage HMO (HMO)	Ada and Canyon Counties		Ada and Canyon Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1969	004	0	2021	01	Regence Blue MedAdvantage HMO Plus (HMO)	Ada and Canyon Counties		Ada and Canyon Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $110.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $110.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1969	006	0	2021	01	Regence | St. Luke's Health Partners Align No Rx (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1969	007	3	2021	01	Regence | St. Luke's Health Partners Align (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1969	007	4	2021	01	Regence | St. Luke's Health Partners Align (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1969	008	1	2021	01	Regence | St. Luke's Health Partners Align Plus (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1969	008	2	2021	01	Regence | St. Luke's Health Partners Align Plus (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1977	001	0	2021	48	Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan)	Upper Peninsula of Michigan		Upper Peninsula of Michigan	1	0	0	853 W. Washington Street		Marquette	MI	49855				853 W. Washington Street		Marquette	MI	49855				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.uphp.com/medicare	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.uphp.com/medicare/providers	www.uphp.com/pharmacy	www.uphp.com/medicare/uphp-mi-health-link/formulary
H1993	001	0	2021	01	Astiva Health Advantage (HMO)	Orange County		Orange County	1	0	0	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://astivahealth.com/	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	https://astivahealth.com/	https://www.elixirsolutions.com/	https://astivahealth.com/
H1993	002	0	2021	01	Astiva Health Value (HMO)	Orange County		Orange County	1	0	0	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://astivahealth.com/	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://astivahealth.com/	https://www.elixirsolutions.com/	https://astivahealth.com/
H1993	003	0	2021	01	Astiva Health Advantage (HMO)	San Diego County		San Diego County	1	0	0	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://astivahealth.com/	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	https://astivahealth.com/	https://www.elixirsolutions.com/	https://astivahealth.com/
H1993	004	0	2021	01	Astiva Health Value (HMO)	San Diego County		San Diego County	1	0	0	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	3200 Bristol St., Suite 600		Costa Mesa	CA	92626		memberservices@astivahealth.com	memberservices@astivahealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://astivahealth.com/	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://astivahealth.com/	https://www.elixirsolutions.com/	https://astivahealth.com/
H1994	001	0	2021	01	SelectHealth Advantage Essential (HMO)	Urban and Northern Utah		Urban and Northern Utah	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	002	0	2021	01	SelectHealth Advantage (HMO)	Gar, Iron, Jua, Mil, Piu, San, Sev, Wash, Wayne Co		Gar, Iron, Jua, Mil, Piu, San, Sev, Wash, Wayne Co	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	003	0	2021	01	SelectHealth Advantage Essential (HMO)	Ada and Canyon Counties		Ada and Canyon Counties	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	004	0	2021	01	SelectHealth Advantage (HMO)	Minidoka and Twin Falls Counties		Minidoka and Twin Falls Counties	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	007	0	2021	01	SelectHealth Advantage Enhanced (HMO)	Urban and Northern Utah		Urban and Northern Utah	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	008	0	2021	01	SelectHealth Advantage Enhanced (HMO)	Ada and Canyon Counties		Ada and Canyon Counties	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	012	0	2021	01	SelectHealth Advantage (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				5000000000207002000307002000407002000507002000607002000709001400	5108002000207002000307002000407002000507002000607002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	013	0	2021	01	SelectHealth Advantage (HMO)	Southwest Idaho		Southwest Idaho	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	014	0	2021	01	SelectHealth Advantage (HMO)	Cassia, Gooding, and Jerome Counties		Cassia, Gooding, and Jerome Counties	1	0	0	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	1		0	1	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	801	0	2021	01	SelectHealth Advantage (HMO)	Utah and Idaho, and Clark and Nye Counties Nevada		Utah and Idaho, and Clark and Nye Counties Nevada	1	3	1	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	802	0	2021	01	SelectHealth Advantage (HMO)	Utah and Idaho, and Clark and Nye Counties Nevada		Utah and Idaho, and Clark and Nye Counties Nevada	1	3	1	PO Box 30196		Salt Lake City	UT	84130												4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1994	803	0	2021	01	SelectHealth Advantage (HMO)	Utah and Idaho, and Clark and Nye Counties Nevada		Utah and Idaho, and Clark and Nye Counties Nevada	1	3	1	PO Box 30196		Salt Lake City	UT	84130				PO Box 30196		Salt Lake City	UT	84130				4000000000207002000307002000407002000507002000607002000709001400	4108002000207002000307002000407002000507002000607002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.selecthealth.org/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.selecthealth.org/medicare	www.selecthealth.org/medicare	www.selecthealth.org/medicare
H1997	002	0	2021	01	Regence BlueAdvantage HMO Plus (HMO)	King, Kitsap, Pierce, Snohomish Counties		King, Kitsap, Pierce, Snohomish Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1997	008	0	2021	01	Regence Valiance (HMO)	Select Counties in Washington		Select Counties in Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1997	009	0	2021	01	Regence BlueAdvantage HMO (HMO)	King, Kitsap, Pierce, Snohomish Counties		King, Kitsap, Pierce, Snohomish Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1997	010	0	2021	01	Regence Align (HMO)	Whatcom and Skagit Counties		Whatcom and Skagit Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H1997	011	0	2021	01	Regence Align Plus (HMO)	Whatcom and Skagit Counties		Whatcom and Skagit Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H2001	001	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Southwest Maine		Southwest Maine	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2001	010	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Southwest Maine		Southwest Maine	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2001	017	0	2021	04	UnitedHealthcare Medicare Advantage Choice (PPO)	Washington County		Washington County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	018	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	North Maine		North Maine	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2001	019	0	2021	04	AARP Medicare Advantage Choice Plan 3 (PPO)	South Maine		South Maine	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2001	816	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	817	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	818	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	819	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84030				P.O. Box 30770		Salt Lake City	UT	84030				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	820	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	821	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	822	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	823	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	824	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	825	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	826	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	827	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	828	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	829	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	830	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	831	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	832	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	833	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	834	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	835	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130		memberservices@mypreferredcare.com	memberservices@mypreferredcare.com	PO Box 30770		Salt Lake City	UT	84130		memberservices@mypreferredcare.com	memberservices@mypreferredcare.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	836	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	837	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	838	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	839	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	840	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	841	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	842	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	843	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	844	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	845	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	846	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	847	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	848	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	849	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	850	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	851	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	852	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	853	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	854	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	855	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	856	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	857	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	858	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2001	859	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2011	001	0	2021	01	Bright Advantage (HMO)	Nashville Metro Area		Nashville Metro Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2011	002	0	2021	01	Bright Advantage Plus (HMO)	Nashville Metro Area		Nashville Metro Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2011	003	0	2021	01	Bright Advantage (HMO)	Memphis Area		Memphis Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2011	004	0	2021	01	Bright Advantage Plus (HMO)	Memphis Area		Memphis Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2020	001	0	2021	04	Clear Spring Health Essential (PPO)	Metro Denver, Boulder and Ft. Collins		Metro Denver, Boulder and Ft. Collins	1	0	0	PO Box 278530		Miramar	FL	33027				PO Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H2020	002	0	2021	04	Clear Spring Health Essential (PPO)	Metro Richmond		Metro Richmond	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H2020	003	0	2021	04	Clear Spring Health Essential (PPO)	Robeson and Scotland Counties		Robeson and Scotland Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H2020	004	0	2021	04	Clear Spring Health Essential Plus (PPO)	Metro Denver, Boulder and Ft. Collins		Metro Denver, Boulder and Ft. Collins	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H2020	005	0	2021	04	Clear Spring Health Essential Plus (PPO)	Robeson and Scotland Counties		Robeson and Scotland Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H2029	001	0	2021	04	HumanaChoice Value H2029-001 (PPO)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000707001800	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	801	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	802	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	805	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	806	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	809	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	810	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	811	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	812	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	813	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2029	814	0	2021	04	Humana Medicare Employer (PPO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2032	001	0	2021	04	BSW SeniorCare Advantage (PPO)	Dallas/Ft. Worth Metro Area		Dallas/Ft. Worth Metro Area	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2032	002	0	2021	04	BSW SeniorCare Advantage Basic (PPO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2032	003	0	2021	04	BSW SeniorCare Advantage Platinum (PPO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2032	801	0	2021	04	BSW SeniorCare Advantage EGWP CY Rx (PPO)	North and Central Texas		North and Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2032	802	0	2021	04	BSW SeniorCare Advantage EGWP CY (PPO)	North and Central Texas		North and Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2032	803	0	2021	04	BSW SeniorCare Advantage EGWP FY Rx (PPO)	North and Central Texas		North and Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2032	804	0	2021	04	BSW SeniorCare Advantage EGWP FY (PPO)	North and Central Texas		North and Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H2034	001	0	2021	01	Community Care's  Partnership Program (HMO D-SNP)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	205 Bishops Way		Brookfield	WI	53005				205 Bishops Way		Brookfield	WI	53005				3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.communitycareinc.org	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.communitycareinc.org	www.communitycareinc.org	www.communitycareinc.org
H2056	001	0	2021	01	Aetna Medicare Elite Plan (HMO)	Treasure Valley		Treasure Valley	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	002	0	2021	01	Aetna Medicare Value Plan (HMO)	Treasure Valley		Treasure Valley	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	003	0	2021	01	Aetna Medicare Elite Plan (HMO)	Greater Portland Metro Area		Greater Portland Metro Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	004	0	2021	01	Aetna Medicare Value Plan (HMO)	Greater Portland Metro Area		Greater Portland Metro Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	005	0	2021	01	Aetna Medicare Elite Plan (HMO)	Southern Oregon		Southern Oregon	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	007	0	2021	01	Aetna Medicare Elite Plan (HMO)	Central Oregon		Central Oregon	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	801	0	2021	01	Aetna Medicare Plan (HMO)	Idaho and Oregon		Idaho and Oregon	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2056	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Idaho and Oregon		Idaho and Oregon	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2064	001	0	2021	20	LIFE Geisinger (PACE)	LIFE Geisinger		LIFE Geisinger	1	3	0									100 North Academy Avenue	MC 24-12	Danville	PA	17822		remcquillan@geisinger.edu	remcquillan@geisinger.edu	2100001200200001200300001200400001200500001200600001200700001200	2100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifegeisinger.org	0	0	1			0					3	0	0		www.lifegeisinger.org	www.lifegeisinger.org
H2064	002	0	2021	20	LIFE Geisinger (PACE)	LIFE Geisinger		LIFE Geisinger	1	3	0									100 North Academy Avenue	MC 24-12	Danville	PA	17822		remcquillan@geisinger.edu	remcquillan@geisinger.edu	2100001200200001200300001200400001200500001200600001200700001200	2100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifegeisinger.org	0	0	1			0					3	0	0		www.lifegeisinger.org	www.lifegeisinger.org
H2108	001	0	2021	01	Cigna TotalCare (HMO D-SNP)	Maryland, Washington DC and Delaware	Cigna TotalCare (HMO D-SNP)	Maryland, Washington DC and Delaware	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	020	0	2021	01	Cigna Traditions Medicare (HMO I-SNP)	Maryland, Washington DC and Delaware	Cigna Traditions Medicare (HMO I-SNP)	Maryland, Washington DC and Delaware	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	022	0	2021	01	Cigna Preferred Medicare (HMO)	Baltimore Area	Cigna Preferred Medicare (HMO)	Baltimore Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	028	0	2021	01	Cigna Preferred Medicare (HMO)	Washington DC and Delaware	Cigna Preferred Medicare (HMO)	Washington DC and Delaware	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	029	0	2021	01	Cigna Achieve Medicare (HMO C-SNP)	Washington DC and Delaware	Cigna Achieve Medicare (HMO C-SNP)	Washington DC and Delaware	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	030	0	2021	01	Cigna Achieve Medicare (HMO C-SNP)	Baltimore Area	Cigna Achieve Medicare (HMO C-SNP)	Baltimore Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	034	0	2021	01	Cigna Preferred Medicare (HMO)	Maryland DC Suburbs	Cigna Preferred Medicare (HMO)	Maryland DC Suburbs	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $280.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $280.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	036	0	2021	01	Cigna Alliance Medicare (HMO)	Baltimore Area	Cigna Alliance Medicare (HMO)	Baltimore Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2108	801	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide MD, DC and DE	Cigna Preferred Medicare (HMO)	Statewide MD, DC and DE	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H2109	001	0	2021	20	The Johns Hopkins Health System Corporation. (PACE)	Parts of Baltimore City and County, Maryland		Parts of Baltimore City and County, Maryland	1	3	0									4940 Eastern Avenue	Mason F. Lord Building East Tower, 1st Floor	Baltimore	MD	21224		Jaistro1@jhmi.edu	Jaistro1@jhmi.edu	2000000000208002000308002000408002000508002000608002000000000000	2000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopkinsbayview.org/hopkinselderplus	0	0	1			0					3	0	0		http://www.hopkinsbayview.org/hopkinselderplus	http://www.hopkinsbayview.org/hopkinselderplus
H2109	002	0	2021	20	The Johns Hopkins Health System Corporation (PACE)	Parts of Baltimore City and County, Maryland		Parts of Baltimore City and County, Maryland	1	3	0									4940 Eastern Avenue	Mason F. Lord Building East Tower, 1st Floor	Baltimore	MD	21224		Jaistro1@jhmi.edu	Jaistro1@jhmi.edu	2000000000208002000308002000408002000508002000608002000000000000	2000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopkinsbayview.org/hopkinselderplus	0	0	1			0					3	0	0		http://www.hopkinsbayview.org/hopkinselderplus	http://www.hopkinsbayview.org/hopkinselderplus
H2120	001	0	2021	01	BlueEssential (HMO C-SNP)	West Tennessee		West Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H2120	002	0	2021	01	BlueEssential (HMO C-SNP)	Middle Tennessee		Middle Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H2120	003	0	2021	01	BlueEssential (HMO C-SNP)	Southeast Tennessee		Southeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H2120	004	0	2021	01	BlueEssential (HMO C-SNP)	Northeast Tennessee		Northeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H2134	001	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	15 Counties in New Mexico		15 Counties in New Mexico	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunitycare.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/formulary
H2134	002	0	2021	01	Allwell Medicare Boost (HMO)	4 Counties in New Mexico		4 Counties in New Mexico	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunitycare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/formulary
H2134	003	0	2021	01	Allwell Dual Medicare Harmony (HMO D-SNP)	15 Counties in New Mexico		15 Counties in New Mexico	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunitycare.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $410.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $410.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/formulary
H2134	004	0	2021	01	Allwell Medicare Complement (HMO)	4 Counties in New Mexico		4 Counties in New Mexico	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunitycare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunity.com/formulary
H2134	005	0	2021	01	Allwell Medicare (HMO)	4 Counties in New Mexico		4 Counties in New Mexico	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunitycare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/formulary
H2134	006	0	2021	01	Allwell Medicare Simple (HMO)	4 Counties in New Mexico		4 Counties in New Mexico	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunitycare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/findadoctor	allwell.westernskycommunitycare.com/formulary
H2134	801	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunity.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunity.com/formulary
H2134	802	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunity.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunity.com/formulary
H2134	803	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.westernskycommunity.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunity.com/findadoctor	allwell.westernskycommunity.com/formulary
H2161	002	0	2021	02	Upper Peninsula Health Plan Advantage (HMO-POS)	Upper Peninsula of Michigan		Upper Peninsula of Michigan	1	0	0	853 W. Washington Street		Marquette	MI	49855				853 W. Washington Street		Marquette	MI	49855				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.uphp.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.uphp.com/medicare/providers	www.uphp.com/pharmacy	www.uphp.com/medicare/upper-peninsula-health-plan-advantage/formulary-advantage/
H2161	003	0	2021	01	Upper Peninsula Health Plan Choice (HMO)	Upper Peninsula of Michigan		Upper Peninsula of Michigan	1	0	0	853 W. Washington Street		Marquette	MI	49855				853 W. Washington Street		Marquette	MI	49855				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.uphp.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.uphp.com/medicare/providers	www.uphp.com/pharmacy	www.uphp.com/medicare/upper-peninsula-health-plan-choice/formulary-choice
H2162	001	0	2021	01	WellCare Value (HMO)	Select counties in NH		Select counties in NH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2162	002	0	2021	01	WellCare Plus (HMO)	Select counties in NH		Select counties in NH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2168	001	0	2021	01	VillageCareMAX Medicare Health Advantage (HMO D-SNP)	Bronx, Kings, New York, and Queens counties	VillageCareMAX Medicare Health Advantage (HMO D-SNP)	Bronx, Kings, New York, and Queens counties	1	0	0	112 Charles Street		New York	NY	12570				112 Charles Street		New York	NY	12570				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.villagecaremax.org	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.villagecaremax.org	www.villagecaremax.org	www.villagecaremax.org
H2168	002	0	2021	01	VillageCareMAX Medicare Total Advantage (HMO D-SNP)	Bronx, Kings, New York, and Queens counties	VillageCareMAX Medicare Total Advantage (HMO D-SNP)	Bronx, Kings, New York, and Queens counties	1	0	0	112 Charles Street		New York	NY	10014				112 Charles Street		New York	NY	10014				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.villagecaremax.org	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.villagecaremax.org	www.villagecaremax.org	www.villagecaremax.org
H2171	001	0	2021	01	Care N' Care Classic (HMO)	Dallas Fort Worth Metro Area		Dallas Fort Worth Metro Area	1	0	0	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	yourteam@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	yourteam@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H2171	801	0	2021	01	Care N' Care Classic CY - MAPD (HMO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H2171	802	0	2021	01	Care N' Care Classic NCY - MAPD (HMO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H2171	803	0	2021	01	Care N' Care Classic CY - MA-Only (HMO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H2171	804	0	2021	01	Care N' Care Classic NCY - MA-Only (HMO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H2172	001	0	2021	01	Kaiser Permanente Medicare Advantage High DC (HMO)	DC		DC	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	002	0	2021	01	Kaiser Permanente Medicare Advantage High MD (HMO)	MD		MD	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	003	0	2021	01	Kaiser Permanente Medicare Advantage Standard DC (HMO)	DC		DC	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	004	0	2021	01	Kaiser Permanente Medicare Advantage Standard MD (HMO)	MD		MD	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	005	0	2021	01	Kaiser Permanente Medicare Advantage w/o Part D (HMO)	DC, MD, VA		DC, MD, VA	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	006	0	2021	01	Kaiser Permanente Medicare Advantage Value Balt (HMO)	Baltimore City and Baltimore County		Baltimore City and Baltimore County	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	008	0	2021	01	Kaiser Permanente Medicare Advantage High VA (HMO)	Northern Virginia		Northern Virginia	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	009	0	2021	01	Kaiser Permanente Medicare Advantage Standard VA (HMO)	Northern Virginia		Northern Virginia	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	010	0	2021	01	Kaiser Permanente Medicare Advantage Value VA (HMO)	Northern Virginia		Northern Virginia	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	011	0	2021	01	Kaiser Permanente Medicare Advantage Value MD (HMO)	Counties: AA, CH, CR, CV, FR, HA, HO, PG, MO		Counties: AA, CH, CR, CV, FR, HA, HO, PG, MO	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	012	0	2021	01	Kaiser Permanente Medicare Advantage Value DC (HMO)	DC		DC	1	0	0	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	801	0	2021	01	Kaiser Permanente Medicare Advantage for Groups (HMO)	DC, MD, VA		DC, MD, VA	1	3	1	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	803	0	2021	01	Kaiser Permanente Medicare Advantage Fed w/Part D (HMO)	DC, MD, VA		DC, MD, VA	1	3	1	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	804	0	2021	01	Kaiser Permanente Medicare Advantage Fed B/D (HMO)	DC, MD, VA		DC, MD, VA	1	3	1	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2172	805	0	2021	01	Kaiser Permanente Medicare Advantage GRP w/o D (HMO)	DC, MD, VA		DC, MD, VA	1	3	1	2101 East Jefferson Street	2nd Floor West	Rockville	MD	20852												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H2174	001	0	2021	01	Trillium Advantage Dual (HMO D-SNP)	Lane County	Trillium Advantage Dual (HMO D-SNP)	Lane County	1	0	0	PO Box 10420		Van Nuys	CA	91410			cs@trilliumchp.com	PO Box 10420		Van Nuys	CA	91410			cs@trilliumchp.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	trilliumadvantage.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	trilliumadvantage.com/findadoctor	trilliumadvantage.com/findadoctor	trilliumadvantage.com/formulary
H2185	001	0	2021	01	LifeWorks Advantage I-SNP (HMO I-SNP)	Virginia (partial)		Virginia (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.lifeworksadvantage.com	1	1	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.lifeworksadvantage.com	www.lifeworksadvantage.com	www.lifeworksadvantage.com
H2196	001	0	2021	01	AARP Medicare Advantage (HMO)	Select Counties in North MS		Select Counties in North MS	1	0	0	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2196	002	0	2021	01	AARP Medicare Advantage (HMO)	Select Counties in South MS		Select Counties in South MS	1	0	0	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2218	001	0	2021	20	Harbor Health Elder Service Plan, Dual Eligible (PACE)	Norfolk,Suffolk, Plymouth,Bristol & Middlesex cty		Norfolk,Suffolk, Plymouth,Bristol & Middlesex cty	1	3	0									1135 Morton Street		Mattapan	MA	02126		kburns@hhsi.us	MOSullivan@hhsi.us	2108002000208301700308301700408301700508301700608301700708002000	2108002000208301700308301700408301700508301700608301700708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.elderserviceplan.org	0	0	1			0					3	0	0		www.eatonapothecary.com	www.elderserviceplan.org
H2218	002	0	2021	20	Harbor Health Elder Service Plan, Medicare only (PACE)	Norfolk,Suffolk,Middlesex,Plymouth & Bristol Cty		Norfolk,Suffolk,Middlesex,Plymouth & Bristol Cty	1	3	0									1135 Morton Street		Mattapan	MA	02126		kburns@hhsi.us	mosullivan@hhsi.us	2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.elderserviceplan.org	0	0	1			0					3	0	0		www.eatonapothecary.com	www.elderserviceplan.org
H2219	001	0	2021	20	Summit ElderCare (PACE)	Full: Worc,Hampden Part: Essex,Hampshire,Middlesex		Full: Worc,Hampden Part: Essex,Hampshire,Middlesex	1	3	0									10 Chestnut Street		Worcester	MA	01608		Navicare/Summit-CS@fallonhealth.org	Navicare/Summit-CS@fallonhealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fallonhealth.org/summit	0	0	1			0					3	0	0	www.fallonhealth.org/summit	NotApplicable	www.fallonhealth.org/summit
H2219	002	0	2021	20	Summit ElderCare (PACE)	Full: Worc,Hampden Part: Essex,Hampshire,Middlesex		Full: Worc,Hampden Part: Essex,Hampshire,Middlesex	1	3	0									10 Chestnut Street		Worcester	MA	01608		Navicare/Summit-CS@fallonhealth.org	Navicare/Summit-CS@fallonhealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fallonhealth.org/summit	0	0	1			0					3	0	0	www.fallonhealth.org/summit	NotApplicable	www.fallonhealth.org/summit
H2220	001	0	2021	20	Upham's Corner Health Committee (PACE)	Upham's Elder Service Plan, inner city of Boston	El Plan Upham's Que Sirve a las Personas Mayores (PACE)	Upham's Elder Service Plan, inner city of Boston	1	3	0									1140 Dorchester Ave		Dorchester	MA	02125		nroach@uphams.org	nroach@uphams.org	2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.uphamselderserviceplan.org	0	0	1			0					3	0	0		http://www.uphamscornerhealthctr.com/	http://www.uphamscornerhealthctr.com/
H2220	002	0	2021	20	Uphams Corner Health Committee (PACE)	Upham's Elder Service Plan, inner city of Boston	El Plan Upham's Que Sirve a las Personas Mayores (PACE)	Upham's Elder Service Plan, inner city of Boston	1	3	0									1140 Dorchester Ave		Dorchester	MA	02125		nroach@uphams.org	nroach@uphams.org	2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.uphamselderserviceplan.org	0	0	1			0					3	0	0		http://www.uphamscornerhealthctr.com/	http://www.uphamscornerhealthctr.com/
H2221	001	0	2021	20	CHA PACE fka ESP of CHA (PACE)	Counties: Middlesex and Suffolk	Comisión de Salud Pública de Cambridge (PACE)	Counties: Middlesex and Suffolk	1	3	0									163 Gore St.		Cambridge	MA	02139		ejean@challiance.org	jgeyerhahn@challiance.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.challiance.org/esp/elder-service-plan	0	0	1			0					3	0	0		http://www.challiance.org/Services/Pharmacy.aspx	none
H2221	002	0	2021	20	CHA PACE fka ESP of CHA (PACE)	Counties:  Middlesex and Suffolk	Comisión de Salud Pública de Cambridge (PACE)	Counties:  Middlesex and Suffolk	1	3	0									270 Green Street		Cambridge	MA	02139		ejean@challiance.org	jgeyerhahn@challiance.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.challiance.org/esp/elder-service-plan	0	0	1			0					3	0	0		http://www.challiance.org/Services/Pharmacy.aspx	none
H2222	002	0	2021	20	Element Care (PACE)	Essex, Middlesex counties		Essex, Middlesex counties	1	3	0									37 Friend Street		Lynn	MA	01902		info@elementcare.org	info@elementcare.org	2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.elementcare.org	0	0	1			0					3	0	0		www.eatonapothecary.com	None
H2222	003	0	2021	20	Element Care (PACE)	Essex, Middlesex counties		Essex, Middlesex counties	1	3	0									37 Friend Street		Lynn	MA	01902		info@elementcare.org	info@elementcare.org	2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.elementcare.org	0	0	1			0					3	0	0		www.eatonapothecary.com	None
H2223	001	0	2021	20	East Boston Elder Service Plan (PACE)	02108, 02128, 02148 - 02152, 02155, 02176, 02180		02108, 02128, 02148 - 02152, 02155, 02176, 02180	1	3	0									10 Gove Street		East Boston	MA	02128				2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ebnhc.org/elderservice.php	0	0	1			0					3	0	0		www.neighborhoodpace.org	www.neighborhoodpace.org
H2223	002	0	2021	20	East Boston Elder Service Plan (PACE)	02108, 02128, 02148 - 02152, 02155, 02176, 02180		02108, 02128, 02148 - 02152, 02155, 02176, 02180	1	3	0									10 Gove Street		East Boston	MA	02128				2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ebnhc.org/elderservice.php	0	0	1			0					3	0	0		www.neighborhoodpace.org	www.neighborhoodpace.org
H2224	001	0	2021	01	Senior Whole Health (HMO D-SNP)	Brstl, Essx, Hmpdn, Mdlsx, Nrflk, Plmth, Sflk, Wor	Senior Whole Health (HMO D-SNP)	Brstl, Essx, Hmpdn, Mdlsx, Nrflk, Plmth, Sflk, Wor	1	0	0	58 Charles Street		Cambridge	MA	02141		info@seniorwholehealth.com	info@seniorwholehealth.com	58 Charles Street		Cambridge	MA	02141		info@seniorwholehealth.com	info@seniorwholehealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.seniorwholehealthMA.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.seniorwholehealth.com	www.seniorwholehealth.com
H2224	003	0	2021	01	Senior Whole Health NHC (HMO D-SNP)	Brstl, Essx, Hmpdn, Mdlsx, Nrflk, Plmth, Sflk, Wor		Brstl, Essx, Hmpdn, Mdlsx, Nrflk, Plmth, Sflk, Wor	1	0	0	58 Charles Street		Cambridge	MA	02141		info@seniorwholehealth.com	info@seniorwholehealth.com	58 Charles Street		Cambridge	MA	02141		info@seniorwholehealth.com	info@seniorwholehealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.seniorwholehealthMA.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.seniorwholehealth.com	www.seniorwholehealth.com
H2225	001	0	2021	01	Senior Care Options Program (HMO D-SNP)	BRI, ESS, FRA, HMD, HMP, MID, NOR, PLY, SUF, WOR		BRI, ESS, FRA, HMD, HMP, MID, NOR, PLY, SUF, WOR	1	0	0	30 Winter Street		Boston	MA	02108				30 Winter Street		Boston	MA	02108				2108001800208002000308002000408002000508002000608002000708001800	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.commonwealthcaresco.org	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.commonwealthcarealliance.org	http://www.commonwealthcarealliance.org/members/pharmacy-program	http://www.commonwealthcarealliance.org/members/pharmacy-program/formulary-2021
H2226	001	0	2021	01	UnitedHealthcare Senior Care Options (HMO D-SNP)	Boston, Springfield and Worcester Metro Areas		Boston, Springfield and Worcester Metro Areas	1	0	0	950 Winter ST STE 3800		Waltham	MA	02451				950 Winter ST STE 3800		Waltham	MA	02451				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2226	003	0	2021	01	UnitedHealthcare Senior Care Options NHC (HMO D-SNP)	Boston, Springfield and Worcester Metro Areas		Boston, Springfield and Worcester Metro Areas	1	0	0	950 Winter ST STE 3800		Waltham	MA	02451				950 Winter ST STE 3800		Waltham	MA	02451				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2228	002	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	010	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	Select Counties in Delaware, Maryland and Virginia		Select Counties in Delaware, Maryland and Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	011	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in Maryland		Select Counties in Maryland	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	013	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	016	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	Select Counties in Oregon		Select Counties in Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	017	0	2021	04	UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)	Select Counties in Oregon		Select Counties in Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	018	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select counties in North Carolina		Select counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	019	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Northeast Indiana		Northeast Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	020	0	2021	04	AARP Medicare Advantage Focus (PPO)	Fort Wayne area		Fort Wayne area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	021	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Indianapolis and Central Indiana		Indianapolis and Central Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $185.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $185.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	022	0	2021	04	AARP Medicare Advantage Choice (PPO)	Evansville area		Evansville area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	023	0	2021	04	AARP Medicare Advantage Choice (PPO)	El Paso and Southwest New Mexico		El Paso and Southwest New Mexico	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	024	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Honolulu County		Honolulu County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	025	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Honolulu, Maui, and Kauai Counties		Honolulu, Maui, and Kauai Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	029	0	2021	04	AARP Medicare Advantage Choice (PPO)	Portland, Salem, and Eugene Metro Areas		Portland, Salem, and Eugene Metro Areas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	030	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	031	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Ada and Canyon counties		Ada and Canyon counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	032	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Ada and Canyon counties		Ada and Canyon counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	035	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Philadelphia Metro Area		Philadelphia Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	036	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Philadelphia Metro Area		Philadelphia Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	037	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Bucks, Chester and Philadelphia counties		Bucks, Chester and Philadelphia counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	039	0	2021	04	UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)	Select Counties in Rhode Island		Select Counties in Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	041	0	2021	04	UnitedHealthcare Dual Complete Choice Premier (PPO D-SNP)	El Paso County		El Paso County	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2228	043	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Honolulu County		Honolulu County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2228	044	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Atlanta and Macon Metro Areas		Atlanta and Macon Metro Areas	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2228	045	0	2021	04	UnitedHealthcare Dual Complete (PPO D-SNP)	Washington, DC		Washington, DC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2228	047	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select counties in Albuquerque		Select counties in Albuquerque	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	049	0	2021	04	AARP Medicare Advantage Choice (PPO)	Santa Fe Metro Area		Santa Fe Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	064	0	2021	04	AARP Medicare Advantage Choice (PPO)	Northwest Indiana		Northwest Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	065	0	2021	04	AARP Medicare Advantage Choice (PPO)	Southeast Indiana		Southeast Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	066	0	2021	04	AARP Medicare Advantage Choice (PPO)	West Indiana		West Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	067	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Honolulu county		Honolulu county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	068	0	2021	04	AARP Medicare Advantage Choice (PPO)	Kauai and Maui Counties		Kauai and Maui Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				7108002000208002000308002000408002000508002000608002000708002000	7108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	071	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	074	0	2021	04	AARP Medicare Advantage Walgreens Plan 1 (PPO)	Maricopa county		Maricopa county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	075	0	2021	04	AARP Medicare Advantage Walgreens Plan 1 (PPO)	Pima county		Pima county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	076	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Greater AZ Area		Greater AZ Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	077	0	2021	04	AARP Medicare Advantage Walgreens Plan 2 (PPO)	Maricopa county		Maricopa county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	079	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Ada and Canyon counties		Ada and Canyon counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	080	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Fort Wayne Metro Area		Fort Wayne Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	081	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Indianapolis Metro Area		Indianapolis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $185.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $185.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	082	0	2021	04	AARP Medicare Advantage Choice (PPO)	Bollinger, Scott and Stoddard Counties		Bollinger, Scott and Stoddard Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	083	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	084	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Select counties in Portland		Select counties in Portland	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	085	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Philadelphia Metro Area		Philadelphia Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	086	0	2021	04	AARP Medicare Advantage Choice Plan 3 (PPO)	Philadelphia Metro Area		Philadelphia Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	088	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Portland, Salem, and Eugene Metro Areas		Portland, Salem, and Eugene Metro Areas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	091	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Indiana		Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	092	0	2021	04	AARP Medicare Advantage Choice Premier (PPO)	Indiana		Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	093	0	2021	04	AARP Medicare Advantage Choice (PPO)	Kent, New Castle, and Sussex counties		Kent, New Castle, and Sussex counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	094	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Greater AZ Area	AARP Medicare Advantage Choice Plan 2 (PPO)	Greater AZ Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	095	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Greater AZ Area		Greater AZ Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	096	0	2021	04	AARP Medicare Advantage Walgreens Plan 2 (PPO)	Pima County		Pima County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	097	0	2021	04	AARP Medicare Advantage Walgreens Plan 3 (PPO)	Maricopa County		Maricopa County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	098	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties Greater NM Area		Select Counties Greater NM Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2228	805	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	807	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	808	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	809	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	810	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	811	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	812	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	813	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	814	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	815	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	816	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	817	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	818	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	610097	9999	www.UHCMedicareSolutions.com
H2228	819	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	820	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	821	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	822	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	823	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	824	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	825	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	826	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	827	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	828	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	829	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	830	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	831	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	832	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	833	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	834	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	835	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	836	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	837	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2228	838	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	National Service Area		National Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2230	002	0	2021	04	Medicare PPO Blue PlusRx (PPO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except Berkshire Dukes and Nantucket	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2230	017	0	2021	04	Medicare PPO Blue SaverRx (PPO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except Berkshire Dukes and Nantucket	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $405.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $405.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2230	018	1	2021	04	Medicare PPO Blue ValueRx (PPO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except BER, DUK, NAN, WOR	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2230	018	2	2021	04	Medicare PPO Blue ValueRx (PPO)	Massachusetts except Berkshire Dukes and Nantucket		Worcester, MA	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2230	801	0	2021	04	Medicare PPO Blue (PPO)	National Network		National Network	1	3	1	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2230	809	0	2021	04	Medicare PPO Blue (PPO)	National Network		National Network	1	3	1	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2235	001	0	2021	01	BayCarePlus Complete (HMO)	Hillsborough, Pasco, Pinellas and Polk counties		Hillsborough, Pasco, Pinellas and Polk counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	BayCarePlus.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	BayCarePlus.org	www.baycarehealthplans.com	www.baycarehealthplans.com
H2235	002	0	2021	01	BayCarePlus Rewards (HMO)	Hillborough, Pasco, Pinellas and Polk Counties		Hillborough, Pasco, Pinellas and Polk Counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	BayCarePlus.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	BayCarePlus.org	www.baycarehealthplans.com	www.baycarehealthplans.com
H2235	003	0	2021	01	BayCarePlus Premier (HMO)	Pinellas County		Pinellas County	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	BayCarePlus.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	BayCarePlus.org	www.baycarehealthplans.com	www.baycarehealthplans.com
H2235	004	0	2021	01	BayCarePlus Signature (HMO)	Hillsborough, Pasco and Polk Counties		Hillsborough, Pasco and Polk Counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	BayCarePlus.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	BayCarePlus.org	www.baycarehealthplans.com	www.baycarehealthplans.com
H2235	801	0	2021	01	BayCarePlus EGWP MAPD calendar (HMO)	Hillsborough, Pasco, Pinellas and Polk counties		Hillsborough, Pasco, Pinellas and Polk counties	1	3	1	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BayCarePlus.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	BayCarePlus.org	www.baycarehealthplans.com	www.baycarehealthplans.com
H2235	802	0	2021	01	BayCarePlus EGWP MAPD non calendar (HMO)	Hillsborough, Pasco, Pinellas and Polk counties		Hillsborough, Pasco, Pinellas and Polk counties	1	3	1	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BayCarePlus.org	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	BayCarePlus.org	www.baycarehealthplans.com	www.baycarehealthplans.com
H2237	001	0	2021	01	iCare Medicare Plan (HMO D-SNP)	Eastern, South Central and Western Wisconsin		Eastern, South Central and Western Wisconsin	1	0	0	1555 N. RiverCenter Drive	Suite 206	Milwaukee	WI	53212		info@icarehealthplan.org	info@icarehealthplan.org	1555 N. RiverCenter Drive	Suite 206	Milwaukee	WI	53212		info@icarehealthplan.org	info@icarehealthplan.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.icarehealthplan.org	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.icarehealthplan.org	www.icarehealthplan.org	www.icarehealthplan.org
H2237	007	0	2021	01	iCare Family Care Partnership (HMO D-SNP)	Milwaukee, Racine, Kenosha, Dane and Sauk Counties		Milwaukee, Racine, Kenosha, Dane and Sauk Counties	1	0	0	1555 N. RiverCenter Drive	Suite 206	Milwaukee	WI	53212		info@icarehealthplan.org	info@icarehealthplan.org	1555 N. Rivercenter Drive	Suite 206	Milwaukee	WI	53212		info@icarehealthplan.org	info@icarehealthplan.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.icarehealthplan.org	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.icarehealthplan.org	www.icarehealthplan.org	www.icarehealthplan.org
H2241	007	1	2021	01	Connected Care (HMO)	Stanislaus and San Luis Obispo Counties	Connected Care (HMO)	Stanislaus County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	007	2	2021	01	Connected Care (HMO)	Stanislaus and San Luis Obispo Counties	Connected Care (HMO)	San Luis Obispo County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	012	0	2021	01	Connected Care (HMO)	Los Angeles County	Connected Care (HMO)	Los Angeles County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	013	0	2021	01	Connected Care (HMO)	Orange and Riverside Counties	Connected Care (HMO)	Orange and Riverside Counties	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	014	0	2021	01	Golden State Senior Health Plan (HMO)	San Francisco County	Golden State Senior Health Plan (HMO)	San Francisco County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	015	0	2021	01	Connected Care (HMO)	San Joaquin County	Connected Care (HMO)	San Joaquin County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	016	0	2021	01	Connected Care (HMO)	San Bernardino County	Connected Care (HMO)	San Bernardino County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	017	0	2021	01	Connected Care (HMO)	San Diego County	Connected Care (HMO)	San Diego County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	018	0	2021	01	Connected Care Select (HMO C-SNP)	Los Angeles County	Connected Care Select (HMO C-SNP)	Los Angeles County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	019	0	2021	01	Connected Care Select (HMO C-SNP)	Orange and Riverside Counties	Connected Care Select (HMO C-SNP)	Orange and Riverside Counties	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	020	0	2021	01	Connected Care Select (HMO C-SNP)	San Luis Obispo County	Connected Care Select (HMO C-SNP)	San Luis Obispo County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2241	021	0	2021	01	Connected Care Select (HMO C-SNP)	Stanislaus County	Connected Care Select (HMO C-SNP)	Stanislaus County	3	0	0	P.O. Box 10729		Newport Beach	CA	92658				P.O. Box 10729		Newport Beach	CA	92658				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gsmhp.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.gsmhp.com	www.gsmhp.com	www.gsmhp.com
H2247	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in MI		Select Counties in MI	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2247	002	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Wayne County		Wayne County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2256	001	1	2021	01	Tufts Medicare Preferred HMO Prime Rx Plus (HMO)	Most of Massachusetts		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	001	2	2021	01	Tufts Medicare Preferred HMO Prime Rx Plus (HMO)	Most of Massachusetts		BARN, BRIS, MIDD, NORF, PLYM Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	001	6	2021	01	Tufts Medicare Preferred HMO Prime Rx Plus (HMO)	Most of Massachusetts		Hampden and Hampshire Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	015	1	2021	01	Tufts Medicare Preferred HMO Prime Rx (HMO)	Most of Massachusetts		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	015	2	2021	01	Tufts Medicare Preferred HMO Prime Rx (HMO)	Most of Massachusetts		BARN, BRIS, MIDD, NORF, PLYM Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	015	6	2021	01	Tufts Medicare Preferred HMO Prime Rx (HMO)	Most of Massachusetts		Hampden and Hampshire Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	016	1	2021	01	Tufts Medicare Preferred HMO Prime No Rx (HMO)	Most of Massachusetts		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	016	2	2021	01	Tufts Medicare Preferred HMO Prime No Rx (HMO)	Most of Massachusetts		BARN, BRIS, MIDD, NORF, PLYM Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	018	1	2021	01	Tufts Medicare Preferred HMO Value Rx (HMO)	Most of Massachusetts		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	018	7	2021	01	Tufts Medicare Preferred HMO Value Rx (HMO)	Most of Massachusetts		BARN, BRIS, MIDD, NORF, PLYM Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	018	8	2021	01	Tufts Medicare Preferred HMO Value Rx (HMO)	Most of Massachusetts		Hampden and Hampshire Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	019	1	2021	01	Tufts Medicare Preferred HMO Value No Rx (HMO)	Most of Massachusetts		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	019	7	2021	01	Tufts Medicare Preferred HMO Value No Rx (HMO)	Most of Massachusetts		BARN, BRIS, MIDD, NORF, PLYM Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	026	1	2021	01	Tufts Medicare Preferred HMO Basic Rx (HMO)	Most of Massachusetts		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	026	2	2021	01	Tufts Medicare Preferred HMO Basic Rx (HMO)	Most of Massachusetts		BARN, BRIS, MIDD, NORF, PLYM Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	026	3	2021	01	Tufts Medicare Preferred HMO Basic Rx (HMO)	Most of Massachusetts		Hampden and Hampshire Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	028	0	2021	01	Tufts Medicare Preferred HMO Saver Rx (HMO)	Most of Massachusetts		Most of Massachusetts	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	029	0	2021	01	Tufts Health Plan Senior Care Options (HMO D-SNP)	Most of Massachusetts		Most of Massachusetts	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_Joyce@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_Joyce@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/sco	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	033	0	2021	01	Tufts Medicare Preferred HMO Prime Rx (HMO)	Worcester County		Worcester County	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	034	0	2021	01	Tufts Medicare Preferred HMO Value Rx (HMO)	Worcester County		Worcester County	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	036	0	2021	01	Tufts Medicare Preferred HMO Basic Rx (HMO)	Worcester County		Worcester County	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	039	0	2021	01	Tufts Medicare Preferred HMO Prime No Rx (HMO)	Worcester County		Worcester County	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	040	0	2021	01	Tufts Medicare Preferred HMO Value No Rx (HMO)	Worcester County		Worcester County	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	041	0	2021	01	Tufts Medicare Preferred HMO Basic No Rx (HMO)	Worcester County		Worcester County	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	042	0	2021	01	Tufts Medicare Preferred HMO Basic No Rx (HMO)	Essex and Suffolk Counties		Essex and Suffolk Counties	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	801	0	2021	01	Tufts Medicare Preferred HMO Rx (HMO)	Most of Massachusetts		Most of Massachusetts	1	3	1	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/plans/employer-plans	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	802	0	2021	01	Tufts Medicare Preferred HMO (HMO)	Most of Massachusetts		Most of Massachusetts	1	3	1	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/plans/employer-plans	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	803	0	2021	01	Tufts Medicare Preferred HMO Rx (HMO)	Most of Massachusetts		Most of Massachusetts	1	3	1	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/plans/employer-plans	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
H2256	808	0	2021	01	Tufts Medicare Preferred HMO (HMO)	Most of Massachusetts		Most of Massachusetts	1	3	1	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/plans/employer-plans	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	https://www.tuftsmedicarepreferred.org/drug-coverage	tuftsmedicarepreferred.org/drug-coverage
H2261	005	0	2021	01	Medicare HMO Blue PlusRx (HMO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except Berkshire Dukes and Nantucket	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	022	1	2021	01	Medicare HMO Blue ValueRx (HMO)	Massachusetts except Berkshire, Dukes, Nantucket		Massachusetts except BER, DUK, NAN, WOR	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	022	2	2021	01	Medicare HMO Blue ValueRx (HMO)	Massachusetts except Berkshire, Dukes, Nantucket		Worcester county	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	023	1	2021	02	Medicare HMO Blue FlexRx (HMO-POS)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except BER, DUK, NAN, WOR	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	023	2	2021	02	Medicare HMO Blue FlexRx (HMO-POS)	Massachusetts except Berkshire Dukes and Nantucket		Worcester, MA	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	024	0	2021	01	Medicare HMO Blue SaverRx (HMO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except Berkshire Dukes and Nantucket	1	0	0	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	801	0	2021	01	Medicare HMO Blue (HMO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except Berkshire Dukes and Nantucket	1	3	1	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2261	809	0	2021	01	Medicare HMO Blue (HMO)	Massachusetts except Berkshire Dukes and Nantucket		Massachusetts except Berkshire Dukes and Nantucket	1	3	1	P. O. Box 55007		Boston	MA	02205		governmentprograms@bcbsma.com	governmentprograms@bcbsma.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossma.com/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.bcbsma.com	http://www.bluecrossma.com/medicare	http://www.bluecrossma.com/medicare
H2288	001	0	2021	01	Bright Advantage (HMO)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2288	002	0	2021	01	Bright Advantage Plus (HMO)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2288	003	0	2021	01	Bright Advantage Special Care (HMO D-SNP)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2288	005	0	2021	01	Bright Advantage Assist (HMO)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2288	009	0	2021	01	Bright Advantage Senior Savings (HMO C-SNP)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	1	4	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2288	010	0	2021	01	Bright Advantage Senior Savings Assist (HMO C-SNP)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	1	4	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H2292	001	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	Upstate New York		Upstate New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2292	002	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	New York City		New York City	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2292	003	0	2021	04	UnitedHealthcare Assisted Living Plan (PPO I-SNP)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2318	001	0	2021	20	PACE Southeast Michigan (PACE)	Michigan: Macomb, Oakland, Wayne Counties		Michigan: Macomb, Oakland, Wayne Counties	1	3	0									24463 W 10 Mile Road		Southfield	MI	48033				2000000000207301700307301700407301700507301700607301700000000000	2000000000207301700307301700407301700507301700607301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacesemi.org	0	0	1			0					3	0	0		www.henryford.com	Milwaukee.PACE@milliman.com
H2318	002	0	2021	20	PACE Southeast Michigan (PACE)	Michigan: Macomb, Oakland, Wayne Counties		Michigan: Macomb, Oakland, Wayne Counties	1	3	0									24463 W 10 Mile Road		Southfield	MI	48033				2000000000207301700307301700407301700507301700607301700000000000	2000000000207301700307301700407301700507301700607301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacesemi.org	0	0	1			0					3	0	0		www.henryford.com	Milwaukee.PACE@milliman.com
H2320	022	1	2021	02	PriorityMedicare Key (HMO-POS)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	022	2	2021	02	PriorityMedicare Key (HMO-POS)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	022	3	2021	02	PriorityMedicare Key (HMO-POS)	68 lower peninsula Michigan counties		Region 3	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	022	4	2021	02	PriorityMedicare Key (HMO-POS)	68 lower peninsula Michigan counties		Region 4	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	022	5	2021	02	PriorityMedicare Key (HMO-POS)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	028	1	2021	02	PriorityMedicare (HMO-POS)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	028	2	2021	02	PriorityMedicare (HMO-POS)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	028	3	2021	02	PriorityMedicare (HMO-POS)	68 lower peninsula Michigan counties		Region 3	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	028	4	2021	02	PriorityMedicare (HMO-POS)	68 lower peninsula Michigan counties		Region 4	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	028	5	2021	02	PriorityMedicare (HMO-POS)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	029	1	2021	02	PriorityMedicare Value (HMO-POS)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	029	2	2021	02	PriorityMedicare Value (HMO-POS)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	029	3	2021	02	PriorityMedicare Value (HMO-POS)	68 lower peninsula Michigan counties		Region 3	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	029	4	2021	02	PriorityMedicare Value (HMO-POS)	68 lower peninsula Michigan counties		Region 4	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	029	5	2021	02	PriorityMedicare Value (HMO-POS)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	802	0	2021	02	PriorityMedicare EG Non-Calendar Year (HMO-POS)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	803	0	2021	02	PriorityMedicare EG Calendar Year (HMO-POS)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	804	0	2021	01	PriorityMedicare EG HMO w PD Non-Cal Year (HMO)	State of Michigan		State of Michigan	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	805	0	2021	01	PriorityMedicare EG HMO w PD Cal Year (HMO)	State of Michigan		State of Michigan	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	810	0	2021	01	PriorityMedicare EG HMO Cal Year (HMO)	State of Michigan		State of Michigan	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	811	0	2021	01	PriorityMedicare EG HMO Non-Cal Year (HMO)	State of Michigan		State of Michigan	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	812	0	2021	02	PriorityMedicare HMO-POS No RX EGWP Calendar (HMO-POS)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2320	813	0	2021	02	PriorityMedicare HMO-POS No RX EGWP Non-Calendar (HMO-POS)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.prioritymedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H2322	004	0	2021	04	HAP Senior Plus Option 4 (PPO)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2322	008	0	2021	04	HAP Senior Plus Option 3 (PPO)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2322	011	0	2021	04	HAP Senior Plus Option 1 (PPO)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Blvd.		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2322	012	0	2021	04	HAP Senior Plus Option 2 (PPO)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Blvd.		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2322	801	0	2021	04	HAP Senior Plus Group (PPO)	United States EG Area		United States EG Area	1	3	1	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2322	803	0	2021	04	HAP Senior Plus Group (PPO)	United States EG Area		United States EG Area	1	3	1	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2334	003	0	2021	04	Clear Spring Health Choice Plan (PPO)	Select South Carolina Counties		Select South Carolina Counties	1	0	0	P.O. BOX 278530		Miramar	FL	33027				P.O. BOX 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H2334	005	0	2021	04	Clear Spring Health Gold Plus (PPO)	Select South Carolina Counties		Select South Carolina Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H2354	015	0	2021	01	HAP Senior Plus (HMO)	Mid, Southwest and Southeast Michigan Counties		Mid, Southwest and Southeast Michigan Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	018	0	2021	01	HAP Senior Plus Henry Ford Tiered Access (HMO)	Wayne, Oakland and Macomb counties		Wayne, Oakland and Macomb counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	019	0	2021	01	HAP Senior Plus Medical Only (HMO)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	021	0	2021	02	HAP Senior Plus Option 1 (HMO-POS)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	022	0	2021	02	HAP Senior Plus Option 2 (HMO-POS)	Mid and Southeast Michigan Counties		Mid and Southeast Michigan Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.hap.org/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	024	0	2021	01	HAP Primary Choice (HMO)	Counties: HIL, JAC, LIV, MAC, OAK, WAS, WAY		Counties: HIL, JAC, LIV, MAC, OAK, WAS, WAY	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	025	0	2021	01	HAP Empowered Duals (HMO D-SNP)	Genesee, Wayne, Oakland and Macomb Counties		Genesee, Wayne, Oakland and Macomb Counties	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	026	0	2021	01	HAP Choice Medicare - West Michigan Option 1 (HMO)	Counties:  KEN, MUS, OCE, OTT		Counties:  KEN, MUS, OCE, OTT	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	027	0	2021	01	HAP Choice Medicare - West Michigan Option 2 (HMO)	Counties:  KEN, MUS, OCE, OTT		Counties:  KEN, MUS, OCE, OTT	1	0	0	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	801	0	2021	01	HAP Senior Plus Group (HMO)	United States EG Area		United States EG Area	1	3	1	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hap.org/medicare	0	0	2	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2354	802	0	2021	02	HAP Senior Plus Group (HMO-POS)	United States EG Area		United States EG Area	1	3	1	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2850 West Grand Boulevard		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	MEM_SVCS@hap.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.hap.org/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.hap.org/medicare	www.hap.org/medicare	www.hap.org/medicare
H2368	001	0	2021	20	InnovAge California PACE Sacramento Dual Eligibles (PACE)	InnovAge California PACE Sacramento Dual Eligibles		InnovAge California PACE Sacramento Dual Eligibles	1	3	0									3870 Rosin Ct.		Sacramento	CA	95834				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.myinnovage.com	0	0	1			0					3	0	0		www.granerx.com	www.myinnovage.com
H2368	002	0	2021	20	InnovAge California PACE Sacramento Medicare Only (PACE)	InnovAge California PACE Sacramento Medicare Only		InnovAge California PACE Sacramento Medicare Only	1	3	0									3870 Rosin Ct.		Sacramento	CA	95834				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.myinnovage.com	0	0	1			0					3	0	0		www.granerx.com	www.myinnovage.com
H2384	001	0	2021	20	Sequoia PACE (PACE)	Parts of Fresno, Kings, Madera and Tulare Counties		Parts of Fresno, Kings, Madera and Tulare Counties	1	3	0									1649 Van Ness Ave		Fresno	CA	93721				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://welbehealth.com/sequoia/	0	0	1			0					3	0	0		https://www.omnicare.com/	NA
H2384	002	0	2021	20	Sequoia PACE (PACE)	Parts of Fresno, Kings, Madera and Tulare Counties		Parts of Fresno, Kings, Madera and Tulare Counties	1	3	0									1649 Van Ness Ave		Fresno	CA	93721				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://welbehealth.com/sequoia/	0	0	1			0					3	0	0		https://www.omnicare.com/	NA
H2386	001	0	2021	20	AllCARE for Seniors - Duals (PACE)	Counties:  Buchanan, Dickenson, Russell, Tazewell		Counties:  Buchanan, Dickenson, Russell, Tazewell	1	3	0									P.O. Box 765		Cedar Bluff	VA	24609		dcollins@aasc.org	dcollins@aasc.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.allcareforseniors.org	0	0	1			0					3	0	0		www.optum.com	www.aasc.org
H2386	002	0	2021	20	AllCARE for Seniors - Medicare only (PACE)	Counties:  Buchanan, Dickenson, Russell, Tazewell		Counties:  Buchanan, Dickenson, Russell, Tazewell	1	3	0									P.O. Box 765		Cedar Bluff	VA	24609		dcollins@aasc.org	dcollins@aasc.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.allcareforseniors.org	0	0	1			0					3	0	0		www.optum.com	www.aasc.org
H2392	001	0	2021	01	Kansas Health Advantage (HMO I-SNP)	Central and East Kansas		Central and East Kansas	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	KansasHealthAdvantage.com	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	KansasHealthAdvantage.com	KansasHealthAdvantage.com	KansasHealthAdvantage.com
H2392	002	0	2021	01	Kansas Health Advantage Plus (HMO I-SNP)	Topeka and Wichita Areas		Topeka and Wichita Areas	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	KansasHealthAdvantage.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	KansasHealthAdvantage.com	KansasHealthAdvantage.com	KansasHealthAdvantage.com
H2400	001	0	2021	01	Signature Advantage Plan (HMO I-SNP)	KY (partial)		KY (partial)	1	0	0	12201 Bluegrass Parkway		Louisville	KY	40299		Deb.Baverman@signatureadvantageplan.com	Deb.Baverman@signatureadvantageplan.com	12201 Bluegrass Parkway		Louisville	KY	40299		Deb.Baverman@signatureadvantageplan.com	Deb.Baverman@signatureadvantageplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.signatureadvantageplan.com	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.signatureadvantageplan.com	www.signatureadvantageplan.com	www.signatureadvantageplan.com
H2400	002	0	2021	01	Signature Advantage Community (HMO I-SNP)	KY (partial)		KY (partial)	1	0	0	12201 Bluegrass Parkway		Louisville	KY	40299				12201 Bluegrass Parkway		Louisville	KY	40299				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.signatureadvantageplan.com	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.signatureadvantageplan.com	www.signatureadvantageplan.com	www.signatureadvantageplan.com
H2406	001	0	2021	04	UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	008	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in the Pan Handle of Florida		Select Counties in the Pan Handle of Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	009	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select counties in Southwest Florida		Select counties in Southwest Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	010	0	2021	04	AARP Medicare Advantage Choice (PPO)	Brevard, Orange, Osceola, and Seminole counties		Brevard, Orange, Osceola, and Seminole counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	011	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select counties in Tampa		Select counties in Tampa	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	012	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in Tallahassee		Select Counties in Tallahassee	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	013	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in Jacksonville		Select Counties in Jacksonville	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	014	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in Gainesville		Select Counties in Gainesville	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	015	0	2021	04	AARP Medicare Advantage Choice (PPO)	Citrus and Levy Counties		Citrus and Levy Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	016	0	2021	04	AARP Medicare Advantage Choice (PPO)	Lake, Marion, and Sumter Counties		Lake, Marion, and Sumter Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	017	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in St. Lucie		Select Counties in St. Lucie	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	018	0	2021	04	AARP Medicare Advantage Choice (PPO)	Broward, Miami-Dade, and Palm Beach Counties		Broward, Miami-Dade, and Palm Beach Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	019	0	2021	04	AARP Medicare Advantage Choice (PPO)	DeSoto, Hardee, and Highlands Counties		DeSoto, Hardee, and Highlands Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2406	805	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	806	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	807	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	808	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	809	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	810	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	811	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	812	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	813	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	814	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	815	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	816	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	817	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	818	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	819	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	820	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	821	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	822	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	823	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	824	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Select Counties		Select Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	825	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	826	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	827	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	828	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	829	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	830	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	831	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	832	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	833	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	834	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2406	835	0	2021	04	UnitedHealthcare Group Medicare Advantage (PPO)	Nationwide		Nationwide	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2416	001	0	2021	01	PrimeWest Senior Health Complete (HMO D-SNP)	Northern, west central, and southwestern Minnesota		Northern, west central, and southwestern Minnesota	1	0	0	3905 Dakota Street		Alexandria	MN	56308		matt.magnuson@primewest.org	matt.magnuson@primewest.org	3905 Dakota Street		Alexandria	MN	56308		matt.magnuson@primewest.org	matt.magnuson@primewest.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.primewest.org/pwshc	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.primewest.org/find-a-health-care-provider	https://primewest.org/drug-search	https://primewest.org/pharmacy-search
H2417	001	0	2021	01	IMCare Classic (HMO D-SNP)	Itasca County		Itasca County	1	0	0	1219 SE 2nd Avenue		Grand Rapids	MN	55744		sarah.duell@co.itasca.mn.us	sarah.duell@co.itasca.mn.us	1219 SE 2nd Avenue		Grand Rapids	MN	55744		sarah.duell@co.itasca.mn.us	sarah.duell@co.itasca.mn.us	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.imcare.org	1	3	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.imcare.org	http://www.caremark.com/wps/portal	http://www.imcare.org
H2419	001	0	2021	01	SeniorCare Complete (HMO D-SNP)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	South Country Health Alliance	2300 Park Drive, Suite 100	Owatonna	MN	55060		members@mnscha.org	members@mnscha.org	South Country Health Alliance	2300 Park Drive, Suite 100	Owatonna	MN	55060		members@mnscha.org	members@mnscha.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.mnscha.org	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mnscha.org	www.mnscha.org	www.mnscha.org
H2422	002	0	2021	01	HealthPartners Minnesota Senior Health Options (HMO D-SNP)	Minneapolis/St. Paul Metro Area		Minneapolis/St. Paul Metro Area	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/msho	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	healthpartners.com/msho	healthpartners.com/msho	healthpartners.com/medicarerx
H2425	001	0	2021	01	SecureBlue (HMO D-SNP)	62 Counties within the State of Minnesota	SecureBlue (HMO D-SNP)	62 Counties within the State of Minnesota	1	0	0	P.O. Box  64033		St Paul	MN	55121				P.O. Box  64033		St Paul	MN	55121				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmn.com/secureblue	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.bluecrossmn.com/secureblue	www.myprime.com	www.myprime.com
H2450	001	0	2021	18	Medica Prime Solution Basic w/Rx 2 (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	002	0	2021	18	Medica Prime Solution Enhanced w/Rx 2 (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	007	0	2021	18	Medica Prime Solution Thrift w/Rx (Cost)	All of SD, select MN, ND, and WI counties		All of SD, select MN, ND, and WI counties	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	016	0	2021	18	Medica Prime Solution Basic w/Rx (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	017	0	2021	18	Medica Prime Solution Enhanced w/Rx (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	022	0	2021	18	Medica Prime Solution Value w/Rx (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	030	0	2021	18	Medica Prime Solution Thrift (Cost)	All of SD, select IA, KS, MN, ND, NE, WI counties		All of SD, select IA, KS, MN, ND, NE, WI counties	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	031	0	2021	18	Medica Prime Solution Value (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	032	0	2021	18	Medica Prime Solution Basic (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	033	0	2021	18	Medica Prime Solution Enhanced (Cost)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	034	0	2021	18	Medica Prime Solution Core (Cost)	All of SD, plus select counties in ND		All of SD, plus select counties in ND	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	035	0	2021	18	Medica Prime Solution Core w/Rx (Cost)	All of SD, plus select counties in ND		All of SD, plus select counties in ND	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	036	0	2021	18	Medica Prime Solution Premier (Cost)	All of SD, plus select counties in ND		All of SD, plus select counties in ND	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	037	0	2021	18	Medica Prime Solution Premier w/Rx (Cost)	All of SD, plus select counties in ND		All of SD, plus select counties in ND	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	038	0	2021	18	Medica Prime Solution Focus (Cost)	Select counties in WI		Select counties in WI	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	039	0	2021	18	Medica Prime Solution Focus w/Rx (Cost)	Select counties in WI		Select counties in WI	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	040	0	2021	18	Medica Prime Solution Total (Cost)	Select counties in WI		Select counties in WI	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	041	0	2021	18	Medica Prime Solution Total w/Rx (Cost)	Select counties in WI		Select counties in WI	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	042	0	2021	18	Medica Prime Solution Premier (Cost)	Select counties in Iowa		Select counties in Iowa	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	043	0	2021	18	Medica Prime Solution Premier (Cost)	Select counties in Nebraska		Select counties in Nebraska	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	044	0	2021	18	Medica Prime Solution Standard (Cost)	All of SD, select MN, and ND counties		All of SD, select MN, and ND counties	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	045	0	2021	18	Medica Prime Solution Core (Cost)	Select counties in IA		Select counties in IA	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	046	0	2021	18	Medica Prime Solution Core (Cost)	Select counties in NE		Select counties in NE	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	047	0	2021	18	Medica Prime Solution Core (Cost)	Select counties in KS		Select counties in KS	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	048	0	2021	18	Medica Prime Solution Premier (Cost)	Select counties in KS		Select counties in KS	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	049	0	2021	18	Medica Prime Solution Standard w/Rx (Cost)	SD and select counties in MN		SD and select counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2450	801	0	2021	18	Medica Group Prime Solution w/Rx (Cost)	All of SD, select IA, KS, MN, ND, NE, WI counties		All of SD, select IA, KS, MN, ND, NE, WI counties	1	3	1	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H2456	002	0	2021	01	UCare's Minnesota Senior Health Options (HMO D-SNP)	Twin Cities Metropolitan area and Greater MN		Twin Cities Metropolitan area and Greater MN	1	0	0	PO Box 52		Minneapolis	MN	55440		SNPsales@ucare.org		PO Box 52		Minneapolis	MN	55440		SNPsales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2458	002	0	2021	01	Medica DUAL Solution (HMO D-SNP)	Specific Minnesota counties		Specific Minnesota counties	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	medica.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	medica.com/DUAL	medica.com/DUAL	medica.com/DUAL
H2459	001	0	2021	02	UCare Value (HMO-POS)	State of Minnesota		State of Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org										3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://search.ucare.org	www.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	020	0	2021	02	UCare Prime (HMO-POS)	45 counties		45 counties	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary/
H2459	021	1	2021	02	UCare Classic (HMO-POS)	44 Counties		Twin Cities Metropolitan Area	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	021	2	2021	02	UCare Classic (HMO-POS)	44 Counties		Northern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	021	3	2021	02	UCare Classic (HMO-POS)	44 Counties		Southern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	023	1	2021	02	UCare Essentials Rx (HMO-POS)	46 Counties		Twin Cities Metropolitan Area	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary/
H2459	023	2	2021	02	UCare Essentials Rx (HMO-POS)	46 Counties		Northern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary/
H2459	024	0	2021	02	UCare Standard (HMO-POS)	Southern Minnesota		Southern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	026	1	2021	02	UCare Complete (HMO-POS)	State of Minnesota		Twin Cities Metropolitan Area	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $235.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $235.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	026	3	2021	02	UCare Complete (HMO-POS)	State of Minnesota		Northern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $235.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $235.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	026	4	2021	02	UCare Complete (HMO-POS)	State of Minnesota		Southern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $235.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $235.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	028	0	2021	02	UCare Prime (HMO-POS)	Southern Minnesota		Southern Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org	sales@ucare.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	029	0	2021	02	UCare Aware (HMO-POS)	46 counties		46 counties	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	030	0	2021	02	UCare Value Plus (HMO-POS)	State of Minnesota		State of Minnesota	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org										3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	031	0	2021	01	UCare Advocate Choice (HMO I-SNP)	Twin Cities and Greater MN:14 counties		Twin Cities and Greater MN:14 counties	1	0	0	PO BOX 52		Minneapolis	MN	55440		SNPsales@ucare.org		PO BOX 52		Minneapolis	MN	55440		SNPsales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	032	0	2021	01	UCare Advocate Plus (HMO I-SNP)	Twin Cities and Greater MN:14 counties		Twin Cities and Greater MN:14 counties	1	0	0	PO BOX 52		Minneapolis	MN	55440		SNPsales@ucare.org		PO BOX 52		Minneapolis	MN	55440		SNPsales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2459	801	0	2021	02	Group UCare (HMO-POS)	Minnesota and 26 Wisconsin Counties		Minnesota and 26 Wisconsin Counties	1	3	1	PO Box 52		Minneapolis	MN	55440		groupsales@ucare.org		PO Box 52		Minneapolis	MN	55440		groupsales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	https://home.ucare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H2461	005	0	2021	18	Platinum Blue Core Plan (Cost)	21 County region	Platinum Blue Core Plan (Cost)	21 County region	1	0	0	3400 Yankee Drive		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H2461	006	0	2021	18	Platinum Blue Choice Plan (Cost)	21 County Region	Platinum Blue Choice Plan (Cost)	21 County Region	1	0	0	3400 Yankee Drive		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H2461	007	0	2021	18	Platinum Blue Complete Plan (Cost)	21 County region	Platinum Blue Complete Plan (Cost)	21 County region	1	0	0	3400 Yankee Drive		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H2461	008	0	2021	18	Platinum Blue Core Plan with Rx (Cost)	21 County Region	Platinum Blue Core Plan with Rx (Cost)	21 County Region	1	0	0	3400 Yankee Drive		Eagan	MN	55121				PO Box 64560		St Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H2461	009	0	2021	18	Platinum Blue Choice Plan with Rx (Cost)	21 County Region	Platinum Blue Choice Plan with Rx (Cost)	21 County Region	1	0	0	3400 Yankee Drive		Eagan	MN	55121				PO Box 64560		St Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H2461	010	0	2021	18	Platinum Blue Complete Plan with Rx (Cost)	21 County Region	Platinum Blue Complete Plan with Rx (Cost)	21 County Region	1	0	0	3400 Yankee Drive		Eagan	MN	55121				PO Box 64560		St Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H2462	004	0	2021	18	HealthPartners Freedom Basic (Cost)	Select MN Counties & Duluth Area		Select MN Counties & Duluth Area	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	010	0	2021	18	HealthPartners Freedom Ultimate (Cost)	Select MN Counties & the Duluth Area		Select MN Counties & the Duluth Area	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	016	0	2021	18	HealthPartners Freedom Balance (Cost)	Select MN Counties & Duluth Area		Select MN Counties & Duluth Area	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	018	0	2021	18	HealthPartners Freedom Vital (Cost)	Select MN Counties & Duluth Area		Select MN Counties & Duluth Area	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	022	0	2021	18	HealthPartners Sanford Basic (Cost)	Sioux Falls, Watertown, Fargo, Jamestown, Bismarck		Sioux Falls, Watertown, Fargo, Jamestown, Bismarck	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	023	0	2021	18	HealthPartners Sanford Vital (Cost)	Sioux Falls, Watertown, Fargo, Jamestown, Bismarck		Sioux Falls, Watertown, Fargo, Jamestown, Bismarck	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	024	0	2021	18	HealthPartners Sanford Active (Cost)	Sioux Falls, Watertown, Fargo, Jamestown, Bismarck		Sioux Falls, Watertown, Fargo, Jamestown, Bismarck	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	025	0	2021	18	HealthPartners Sanford Ultimate (Cost)	Sioux Falls, Watertown, Fargo, Jamestown, Bismarck		Sioux Falls, Watertown, Fargo, Jamestown, Bismarck	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	026	0	2021	18	HealthPartners Freedom Basic WI (Cost)	Select Counties in Western WI		Select Counties in Western WI	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	027	0	2021	18	HealthPartners Freedom Vital WI (Cost)	Select Counties in Western WI		Select Counties in Western WI	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	028	0	2021	18	HealthPartners Freedom Balance WI (Cost)	Select Counties in Western WI		Select Counties in Western WI	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	801	0	2021	18	HealthPartners Retiree Group Calendar Year (Cost)	Select Counties in MN, WI, ND, and SD		Select Counties in MN, WI, ND, and SD	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2462	802	0	2021	18	HealthPartners Retiree Group Non-Calendar Year (Cost)	Select Counties in MN, WI, ND, and SD		Select Counties in MN, WI, ND, and SD	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H2463	001	0	2021	01	Humana Gold Plus H2463-001 (HMO)	Pinal and Yuma Counties		Pinal and Yuma Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	003	0	2021	01	Humana Gold Plus H2486-003 (HMO)	Davis, Salt Lake, Utah and Weber counties		Davis, Salt Lake, Utah and Weber counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	005	0	2021	01	Humana Community (HMO)	Ada, Canyon, and Payette counties		Ada, Canyon, and Payette counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	006	0	2021	01	Humana Gold Plus H2486-006 (HMO)	Snohomish County		Snohomish County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	007	0	2021	01	Humana Gold Plus H2486-007 (HMO)	Clark County		Clark County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	008	0	2021	01	Humana Gold Plus H2486-008 (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	801	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Utah		Select counties in Utah	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	802	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Utah		Select counties in Utah	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	805	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Utah		Select counties in Utah	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2486	806	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Utah		Select counties in Utah	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2491	004	0	2021	01	'Ohana Liberty (HMO D-SNP)	Select counties in HI		Select counties in HI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ohanahealthplan.com/medicare	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare
H2491	006	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	007	0	2021	01	WellCare Value (HMO)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	008	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	009	0	2021	01	'Ohana Value (HMO)	Select counties in HI		Select counties in HI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ohanahealthplan.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare
H2491	010	0	2021	01	WellCare Compass (HMO)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	011	0	2021	01	WellCare Freedom (HMO D-SNP)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	012	0	2021	01	WellCare Pinnacle (HMO D-SNP)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	013	0	2021	01	'Ohana Plus (HMO)	Select counties in HI		Select counties in HI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ohanahealthplan.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare
H2491	014	0	2021	01	WellCare Baton Rouge Preferred (HMO)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2491	015	0	2021	01	'Ohana Value (HMO)	Select counties in HI		Select counties in HI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ohanahealthplan.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare	www.ohanahealthplan.com/medicare
H2491	016	0	2021	01	WellCare Endurance (HMO)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2506	001	0	2021	48	Aetna Better Health Premier Plan (Medicare-Medicaid Plan)	Chicago Metro area		Chicago Metro area	1	0	0	7400 W. Campus Rd., MC F494		New Albany	OH	43054				7400 W. Campus Rd., MC F494		New Albany	OH	43054				9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.aetnabetterhealth.com/illinois	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	http://www.aetnabetterhealth.com/illinois	http://www.aetnabetterhealth.com/illinois	http://www.aetnabetterhealth.com/illinois
H2531	001	0	2021	48	UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)	Select Counties in Ohio	UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)	Select Counties in Ohio	1	0	0	9200 Worthington Road		Westerville	OH	43082				9200 Worthington Road		Westerville	OH	43082				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.uhccommunityplan.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.uhccommunityplan.com	www.optumrx.com	www.uhccommunityplan.com
H2533	001	0	2021	48	Molina Dual Options (Medicare-Medicaid Plan)	SC – 39 of 46 counties		SC – 39 of 46 counties	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H2537	001	0	2021	20	SpiriTrust Lutheran LIFE - Dual (PACE)	Franklin, Cumberland, Perry Counties		Franklin, Cumberland, Perry Counties	1	3	0									840 Fifth Avenue		Chambersburg	PA	17201				2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.spiritrustlutheranlife.org	0	0	1			0					3	0	0		carekinesis.com	spiritrustlutheranlife.org
H2537	002	0	2021	20	SpiriTrust Lutheran LIFE  - Medicare Only (PACE)	Franklin, Cumberland, Perry Counties		Franklin, Cumberland, Perry Counties	1	3	0									840 Fifth Avenue		Chambersburg	PA	17201				2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.spiritrustlutheranlife.org	0	0	1			0					3	0	0		carekinesis.com	spiritrustlutheranlife.org
H2563	004	0	2021	01	Optima Community Complete (HMO D-SNP)	Virginia		Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	005	1	2021	01	Optima Medicare Prime (HMO)	Greater Hampton Roads, Virginia		Greater Hampton Roads, VA - Southside	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	005	2	2021	01	Optima Medicare Prime (HMO)	Greater Hampton Roads, Virginia		Greater Hampton Roads, VA - Peninsula	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	008	0	2021	01	Optima Medicare Value (HMO)	Northern Virginia		Northern Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	009	0	2021	01	Optima Medicare Value (HMO)	Central Virginia		Central Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	012	0	2021	01	Optima Medicare Prime (HMO)	Northern Virginia		Northern Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	013	0	2021	01	Optima Medicare Prime (HMO)	Central Virginia		Central Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	014	0	2021	01	Optima Medicare Classic (HMO)	Virginia		Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	015	0	2021	01	Optima Medicare Value (HMO)	Southwest Virginia		Southwest Virginia	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimhealth.com/medicare
H2563	016	0	2021	01	Optima Medicare Value (HMO)	Roanoke/ Alleghany and surrounding counties		Roanoke/ Alleghany and surrounding counties	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	017	1	2021	01	Optima Medicare Value (HMO)	Greater Hampton Roads, Virginia		Greater Hampton Roads, VA - Southside	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	017	2	2021	01	Optima Medicare Value (HMO)	Greater Hampton Roads, Virginia		Greater Hampton Roads, VA - Peninsula	1	0	0	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	801	0	2021	01	Optima Medicare - MAPD Calendar Year (HMO)	Virginia		Virginia	1	3	1	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	802	0	2021	01	Optima Medicare - MAPD Non-Calendar Year (HMO)	Virginia		Virginia	1	3	1	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	803	0	2021	01	Optima Medicare - MA Only Calendar Year (HMO)	Virginia		Virginia	1	3	1	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2563	804	0	2021	01	Optima Medicare - MA Only Non-Calendar Year (HMO)	Virginia		Virginia	1	3	1	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.optimahealth.com/medicare	www.optimahealth.com	www.optimahealth.com/medicare
H2577	001	1	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Select counties in Colorado		Larimer and Weld counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	001	2	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Select counties in Colorado		El Paso, Fremont, Pueblo, and Teller counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	002	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Select counties in Denver		Select counties in Denver	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	003	1	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Select counties in Colorado		Larimer and Weld counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	003	2	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Select counties in Colorado		El Paso, Fremont, Pueblo, and Teller counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	004	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	005	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	006	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	007	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Nashville Metro Area		Nashville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	008	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Memphis Metro Area		Memphis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	009	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Northern VA and Washington DC Area		Northern VA and Washington DC Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	011	0	2021	04	AARP Medicare Advantage Choice (PPO)	VA Tiderwater PPO		VA Tiderwater PPO	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	013	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Richmond Metro Area		Richmond Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	014	0	2021	04	AARP Medicare Advantage Choice (PPO)	All of VA		All of VA	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	015	0	2021	04	AARP Medicare Advantage Patriot (PPO)	VA		VA	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	016	0	2021	04	AARP Medicare Advantage Choice (PPO)	NC Asheville LPPO $0		NC Asheville LPPO $0	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	017	0	2021	04	AARP Medicare Advantage Choice (PPO)	NC Triangle LPPO $0		NC Triangle LPPO $0	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	018	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	NC Coastal Plains+Sandhills LPPO Mid Premium		NC Coastal Plains+Sandhills LPPO Mid Premium	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	019	0	2021	04	AARP Medicare Advantage Patriot (PPO)	North Carolina		North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2577	020	0	2021	04	UnitedHealthcare Medicare Advantage Choice (PPO)	Select Counties for Tennessee		Select Counties for Tennessee	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H2577	021	0	2021	04	AARP Medicare Advantage Choice (PPO)	West Pennsylvania		West Pennsylvania	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2582	002	0	2021	01	Rocky Mountain Health Plans DualCare Plus (HMO D-SNP)	Delta, La Plata, Mesa, Montezuma Counties		Delta, La Plata, Mesa, Montezuma Counties	1	0	0	P.O. Box 10600		Grand Junction	CO	81502				P.O. Box 10600		Grand Junction	CO	81502				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.rmhpdualcare.org	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.rmhpdualcare.org	www.rmhpdualcare.org	www.rmhpdualcare.org
H2582	004	0	2021	01	Rocky Mountain Health Plans CareAdvantage Value (HMO)	Delta, La Plata, Mesa, Montezuma Counties		Delta, La Plata, Mesa, Montezuma Counties	1	0	0	P.O. Box 10600		Grand Junction	CO	81502				P.O. Box 10600		Grand Junction	CO	81502				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.rmhpMedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.rmhpMedicare.org	www.rmhpMedicare.org	www.rmhpMedicare.org
H2582	005	0	2021	01	Rocky Mountain Health Plans CareAdvantage Enhanced (HMO)	Delta, La Plata, Mesa, Montezuma Counties		Delta, La Plata, Mesa, Montezuma Counties	1	0	0	P.O. Box 10600		Grand Junction	CO	81502				P.O. Box 10600		Grand Junction	CO	81502				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.rmhpMedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.rmhpMedicare.org	www.rmhpMedicare.org	www.rmhpMedicare.org
H2591	801	0	2021	04	Medicare Employer PPO (PPO)	Health Alliance Medicare		Health Alliance Medicare	1	3	1	3310 Fields South Drive		Champaign	IL	61822		mwmedicare@healthalliance.org	mwmedicare@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H2591	802	0	2021	04	Health Alliance Medicare (PPO)	Health Alliance Medicare		Health Alliance Medicare	1	3	1	3310 Fields South Drive		Champaign	IL	61822		mwmedicare@healthalliance.org	mwmedicare@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		mwmedicare@healthalliance.org	mwmedicare@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H2591	803	0	2021	04	Health Alliance Medicare (non calendar) (PPO)	Health Alliance Medicare  (non calendar)		Health Alliance Medicare  (non calendar)	1	3	1	3310 Fields South Drive		Champaign	IL	61822		mwmedicare@healthalliance.org	mwmedicare@healthalliance.org	3310 Fields South Drive		Champaign	IL	61822		mwmedicare@healthalliance.org	mwmedicare@healthalliance.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H2593	001	0	2021	01	Amerivantage Classic (HMO)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	003	0	2021	01	Amerivantage CareMore Care To You (HMO I-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	005	0	2021	01	Amerivantage Lung Care (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	006	0	2021	01	Amerivantage Diabetes Care (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	013	0	2021	01	Amerivantage Heart Care (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	018	0	2021	01	Amerivantage Smart Value (HMO)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	019	0	2021	01	Amerivantage CareMore Care To You (HMO I-SNP)	Maricopa County		Maricopa County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	021	0	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	022	0	2021	01	Amerivantage Classic (HMO)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	023	0	2021	01	Amerivantage Classic (HMO)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	024	0	2021	01	Amerivantage Plus (HMO)	Shelby County		Shelby County	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	025	0	2021	01	Amerivantage Balance (HMO)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	026	0	2021	01	Amerivantage Select (HMO)	San Antonio Area		San Antonio Area	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	027	0	2021	01	Amerivantage Select (HMO)	El Paso County		El Paso County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	028	1	2021	01	Amerivantage Classic (HMO)	Select TX  counties		Houston Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	028	2	2021	01	Amerivantage Classic (HMO)	Select TX  counties		Dallas-Fort Worth Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	028	3	2021	01	Amerivantage Classic (HMO)	Select TX  counties		San Antonio Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	028	4	2021	01	Amerivantage Classic (HMO)	Select TX  counties		El Paso and Hudspeth Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	028	5	2021	01	Amerivantage Classic (HMO)	Select TX  counties		Lubbock Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	028	6	2021	01	Amerivantage Classic (HMO)	Select TX  counties		Austin Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	029	0	2021	01	Amerivantage Select (HMO)	Houston Metro		Houston Metro	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	030	1	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Texas		Houston Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	030	2	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Texas		Dallas-Fort Worth Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	030	3	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Texas		San Antonio Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	030	4	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Texas		El Paso and Hudspeth Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	030	5	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Texas		Lubbock Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	030	6	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Select Counties in Texas		Austin Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	031	0	2021	02	Amerivantage ESRD Care (HMO-POS C-SNP)	Select Counties in Texas		Select Counties in Texas	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.amerigroup.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	032	0	2021	01	Amerivantage Dual Secure (HMO D-SNP)	Houston Area and Surrounding Counties		Houston Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	033	0	2021	01	Amerivantage Dual Secure (HMO D-SNP)	Dallas-Fort Worth Area and Surrounding Counties		Dallas-Fort Worth Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	034	0	2021	01	Amerivantage Dual Secure (HMO D-SNP)	San Antonio Area and Surrounding Counties		San Antonio Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	035	0	2021	01	Amerivantage Dual Secure (HMO D-SNP)	El Paso, Hudspeth		El Paso, Hudspeth	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	036	0	2021	01	Amerivantage Dual Secure (HMO D-SNP)	Austin Area and Surrounding Counties		Austin Area and Surrounding Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	037	0	2021	01	Amerivantage Diabetes Care (HMO C-SNP)	Harris County		Harris County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	038	0	2021	01	Amerivantage Heart Care (HMO C-SNP)	Harris County		Harris County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	039	0	2021	01	Amerivantage Lung Care (HMO C-SNP)	Harris County		Harris County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	040	0	2021	01	Amerivantage CareMore ESRD Care (HMO C-SNP)	Pima County		Pima County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	//shop.amerigroup.com/medicare	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	041	0	2021	01	Amerivantage Diabetes Care (HMO C-SNP)	Tarrant County		Tarrant County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	042	0	2021	01	Amerivantage Care To You (HMO I-SNP)	Harris and Tarrant Counties		Harris and Tarrant Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H2593	802	0	2021	01	Amerivantage EGWP MAPD (HMO)	Arizona		Arizona	1	3	1	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H2610	005	0	2021	01	Essence Advantage (HMO)	St. Louis Metropolitan Area		St. Louis Metropolitan Area	1	0	0	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2610	006	0	2021	01	Essence Advantage Plus (HMO)	St. Louis Metropolitan Area		St. Louis Metropolitan Area	1	0	0	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2610	011	0	2021	01	Essence Advantage (HMO)	Columbia Metropolitan Area		Columbia Metropolitan Area	1	0	0	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2610	015	0	2021	01	CoxHealth MedicarePlus (HMO)	Southwest Missouri		Southwest Missouri	1	0	0	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2610	016	0	2021	01	Essence Advantage Select (HMO)	St. Louis Metropolitan Area		St. Louis Metropolitan Area	1	0	0	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2610	803	0	2021	01	Essence Advantage EGWP MAPD calendar (HMO)	MO and IL Service Area		MO and IL Service Area	1	3	1	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2610	804	0	2021	01	Essence Advantage EGWP MAPD non-calendar (HMO)	MO and IL Service Area		MO and IL Service Area	1	3	1	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	PO Box 12487		St. Louis	MO	63132		sales@essencehealthcare.com	customerservice@essencehealthcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.essencehealthcare.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.essencehealthcare.com	https://www.essencehealthcare.com/	https://www.everythingessence.com/s/Essence_Formulary
H2624	001	0	2021	01	HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)	Greensboro (Guilford County)		Greensboro (Guilford County)	1	0	0	7800 McCloud Rd	Suite 100	Greensboro	NC	27409		conciergehta@healthteamadvantage.com	conciergehta@healthteamadvantage.com	7800 McCloud Rd	Suite 100	Greensboro	NC	27409		conciergehta@healthteamadvantage.com	conciergehta@healthteamadvantage.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthteamadvantage.com	1	4	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.healthteamadvantage.com	www.healthteamadvantage.com	www.healthteamadvantage.com
H2663	002	0	2021	01	Aetna Medicare Advantra 2 (HMO)	St Louis Missouri Metro Area		St Louis Missouri Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	005	0	2021	01	Aetna Medicare Gold Advantage Prime (HMO)	St Louis Missouri Metro Area		St Louis Missouri Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	GoldenMedicare@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	006	0	2021	02	Aetna Medicare Advantra 1 (HMO-POS)	St Louis Missouri Metro Area		St Louis Missouri Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	015	0	2021	02	Aetna Medicare Prime (HMO-POS)	St Louis Missouri Metro Area		St Louis Missouri Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	017	0	2021	01	Aetna Medicare UnityPoint Health Prime (HMO)	Peoria and Tazewell Counties		Peoria and Tazewell Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	021	0	2021	01	Aetna Medicare Premier (HMO)	Southwest Missouri		Southwest Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	022	0	2021	01	Aetna Medicare Eagle (HMO)	Southwest Missouri		Southwest Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	023	0	2021	02	Aetna Medicare Premier Plus (HMO-POS)	Southwest Missouri		Southwest Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	025	0	2021	01	Aetna Medicare Eagle (HMO)	Limited counties Missouri and Kansas		Limited counties Missouri and Kansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	026	0	2021	01	Aetna Medicare Premier (HMO)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	028	0	2021	01	Aetna Medicare Premier (HMO)	Wichita Kansas Area		Wichita Kansas Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	029	0	2021	01	Aetna Medicare Premier (HMO)	Northwest Arkansas		Northwest Arkansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	032	0	2021	01	Aetna Medicare Gold Advantage Value Prime (HMO)	St Louis and surrounding counties IL-MO		St Louis and surrounding counties IL-MO	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	034	0	2021	01	Aetna Medicare Premier Plan (HMO)	Oklahoma City and Surrounding Counties		Oklahoma City and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	035	0	2021	01	Aetna Medicare Premier Preferred (HMO)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	036	0	2021	01	Aetna Medicare Premier Preferred (HMO)	Southwest Missouri		Southwest Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	805	0	2021	01	Aetna Medicare Plan (HMO)	Missouri and Illinois		Missouri and Illinois	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2663	810	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Kansas, Missouri, Illinois		Kansas, Missouri, Illinois	1	3	1	151 Famington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Famington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H2678	001	0	2021	01	MoreCare For You (HMO)	Cook County	MoreCare For You (HMO)	Cook County	1	0	0	P.O. Box 64540		Chicago	IL	60664				P.O. Box 64540		Chicago	IL	60664				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mymorecare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.mymorecare.com	www.mymorecare.com	www.mymorecare.com
H2678	002	0	2021	01	MoreCare + (HMO C-SNP)	Cook County	MoreCare + (HMO C-SNP)	Cook County	1	0	0	P.O. Box 64540		Chicago	IL	60664				P.O. Box 64540		Chicago	IL	60664				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mymorecare.com	1	4	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.mymorecare.com	www.mymorecare.com	www.mymorecare.com
H2678	003	0	2021	01	MoreCare Home (HMO I-SNP)	Cook County	MoreCare Home (HMO I-SNP)	Cook County	1	0	0	P.O. Box 64540		Chicago	IL	60664				P.O. Box 64540		Chicago	IL	60664				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.mymorecare.com	1	1	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $365.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $365.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mymorecare.com	www.mymorecare.com	www.mymorecare.com
H2678	004	0	2021	01	MoreCare At Home (HMO I-SNP)	Cook County	MoreCare At Home (HMO I-SNP)	Cook County	1	0	0	P.O. Box 64540		Chicago	IL	60664				P.O. Box 64540		Chicago	IL	60664				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.mymorecare.com	1	1	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mymorecare.com	www.mymorecare.com	www.mymorecare.com
H2697	001	0	2021	01	Devoted Health Core (HMO)	Metro Cleveland, Akron/Canton, Sandusky		Metro Cleveland, Akron/Canton, Sandusky	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H2697	002	0	2021	01	Devoted Health Prime (HMO)	Metro Cleveland, Akron/Canton, Sandusky		Metro Cleveland, Akron/Canton, Sandusky	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H2697	003	0	2021	01	Devoted Health Saver (HMO)	Metro Cleveland, Akron/Canton, Sandusky		Metro Cleveland, Akron/Canton, Sandusky	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H2722	001	0	2021	02	Vantage TRADITIONAL PLUS (HMO-POS)	South Arkansas		South Arkansas	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H2722	002	0	2021	02	Vantage BASIC (HMO-POS)	South Arkansas		South Arkansas	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H2722	003	0	2021	02	Vantage DUAL PLUS (HMO-POS D-SNP)	South Arkansas		South Arkansas	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H2722	004	0	2021	02	Vantage STANDARD (HMO-POS)	South Arkansas		South Arkansas	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H2722	801	0	2021	02	Vantage - MAPD EGWP CY (HMO-POS)	Arkansas		Arkansas	1	3	1	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H2765	001	0	2021	02	Summit Health Core (HMO-POS)	Eastern Oregon		Eastern Oregon	1	0	0	P.O. Box 820070		Portland	OR	97282												5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	yoursummithealth.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	yoursummithealth.com	yoursummithealth.com	yoursummithealth.com
H2765	002	0	2021	01	Summit Health Value + Rx (HMO)	Eastern Oregon		Eastern Oregon	1	0	0	P.O. Box 820070		Portland	OR	97282				P.O. Box 22859		Portland	OR	97269				5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	yoursummithealth.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	yoursummithealth.com	yoursummithealth.com	yoursummithealth.com
H2765	003	0	2021	02	Summit Health Standard + Rx (HMO-POS)	Eastern Oregon		Eastern Oregon	1	0	0	P.O. Box 820070		Portland	OR	97282				P.O. Box 22859		Portland	OR	97269				5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	yoursummithealth.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $230.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $230.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	yoursummithealth.com	yoursummithealth.com	yoursummithealth.com
H2765	004	0	2021	02	Summit Health Premier + Rx (HMO-POS)	Eastern Oregon		Eastern Oregon	1	0	0	P.O. Box 820070		Portland	OR	97282				P.O. Box 22859		Portland	OR	97269				5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	yoursummithealth.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	yoursummithealth.com	yoursummithealth.com	yoursummithealth.com
H2775	100	0	2021	04	WellCare Today's Options Advantage Plus 750B (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	105	0	2021	04	WellCare Today's Options Advantage Plus 150A (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	106	0	2021	04	WellCare Today's Options Advantage Plus 550B (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	108	0	2021	04	WellCare Today's Options Advantage 300 (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	109	0	2021	04	WellCare Today's Options Advantage Plus 550B (PPO)	All counties in ME		All counties in ME	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	111	0	2021	04	WellCare Absolute (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	112	0	2021	04	WellCare Imperial (PPO D-SNP)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	113	0	2021	04	WellCare Summit (PPO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	801	0	2021	04	Today's Options PPO - MA Group Plan (PPO)	National		National	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	802	0	2021	04	Today's Options PPO - MAPD Group Plan (PPO)	National		National	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2775	803	0	2021	04	Today's Options PPO - MAPD Group Plan - NCY (PPO)	National		National	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2782	002	0	2021	01	Western Health Advantage MyCare (HMO)	Northern California	Western Health Advantage MyCare (HMO)	Northern California	1	0	0	2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.westernhealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	mywha.org/MyCareDoctors	medicare.westernhealth.com	medicare.westernhealth.com
H2782	003	0	2021	01	Western Health Advantage MyCare Plus (HMO)	Northern California	Western Health Advantage MyCare Plus (HMO)	Northern California	1	0	0	2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.westernhealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	mywha.org/MyCareDoctors	medicare.westernhealth.com	medicare.westernhealth.com
H2782	801	0	2021	01	Western Health Advantage MyCare EGWP (HMO)	Northern California	Western Health Advantage MyCare EGWP (HMO)	Northern California	1	3	1	2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.westernhealth.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	mywha.org/MyCareDoctors	medicare.westernhealth.com	medicare.westernhealth.com
H2782	802	0	2021	01	Western Health Advantage MyCare EGWP MAPD (HMO)	Northern California		Northern California	1	3	1	2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.westernhealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	mywha.org/MyCareDoctors	medicare.westernhealth.com	medicare.westernhealth.com
H2782	803	0	2021	01	Western Health Advantage MyCare EGWP MA Fiscal (HMO)	Northern California		Northern California	1	3	1	2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.westernhealth.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	mywha.org/MyCareDoctors	medicare.westernhealth.com	medicare.westernhealth.com
H2782	804	0	2021	01	Western Health Advantage MyCare EGWP MAPD Fiscal (HMO)	Northern California		Northern California	1	3	1	2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				2349 Gateway Oaks Drive, Suite 100		Sacramento	CA	95833				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.westernhealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	mywha.org/MyCareDoctors	medicare.westernhealth.com	medicare.westernhealth.com
H2793	003	0	2021	01	Imperial Insurance Company Traditional (HMO)	AZ,TX,NM,NV,UT	Imperial Insurance Company Traditional (HMO)	AZ,TX,NM,NV,UT	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000206002000306002000406002000506002000606002000000000000	5106002000206002000306002000406002000506002000606002000706002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H2793	004	0	2021	01	Imperial Insurance Company Dual (HMO D-SNP)	TX	Imperial Insurance Company Dual (HMO D-SNP)	TX	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000206002000306002000406002000506002000606002000000000000	5106002000206002000306002000406002000506002000606002000706002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H2793	005	0	2021	01	Imperial Insurance Value (HMO C-SNP)	AZ,TX,NM,NV,UT	Imperial Insurance Value (HMO C-SNP)	AZ,TX,NM,NV,UT	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000206002000306002000406002000506002000606002000000000000	5106002000206002000306002000406002000506002000606002000706002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H2793	007	0	2021	01	Imperial Insurance Traditional Plus (HMO)	AZ, UT, NV, NM	Imperial Insurance Traditional Plus (HMO)	AZ, UT, NV, NM	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000206002000306002000406002000506002000606002000000000000	5106002000206002000306002000406002000506002000606002000706002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H2802	001	0	2021	02	AARP Medicare Advantage (HMO-POS)	Omaha Metro area		Omaha Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	007	0	2021	02	AARP Medicare Advantage Profile (HMO-POS)	Fort Wayne area		Fort Wayne area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $210.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $210.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	008	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	South Bend area		South Bend area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	010	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Indianapolis and Central Indiana		Indianapolis and Central Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	012	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Evansville area		Evansville area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	015	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Northeast Indiana		Northeast Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	016	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Southeast Indiana		Southeast Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	018	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Northwest Indiana		Northwest Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	020	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	West Indiana		West Indiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	024	0	2021	01	AARP Medicare Advantage Access (HMO)	Chicago Metro area		Chicago Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	025	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Chicago Metro area		Chicago Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	026	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Chicago Metro area		Chicago Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $60.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $60.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	027	0	2021	02	UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP)	Chicago Metro area		Chicago Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	028	0	2021	02	AARP Medicare Advantage (HMO-POS)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	029	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Jefferson City and Columbia Metro Areas		Jefferson City and Columbia Metro Areas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	030	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Springfield Metro Area		Springfield Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	031	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Springfield Metro Area		Springfield Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	032	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	033	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	034	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Butler, Harvey, and Sedgwick Counties		Butler, Harvey, and Sedgwick Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	035	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Butler, Harvey, and Sedgwick Counties		Butler, Harvey, and Sedgwick Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	041	0	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	044	0	2021	01	UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	048	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Columbia Metro Area		Columbia Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	049	0	2021	02	AARP Medicare Advantage (HMO-POS)	Bollinger, Scott and Stoddard Counties		Bollinger, Scott and Stoddard Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	050	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	Missouri and Illinois		Missouri and Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H2802	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select Counties in Alabama		Select Counties in Alabama	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCRetiree.com	www.UHCRetiree.com	www.UHCRetiree.com
H2802	802	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select Counties in Alabama		Select Counties in Alabama	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select Counties in Alabama		Select Counties in Alabama	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	St Louis Area		St Louis Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCRetiree.com	www.UHCRetiree.com	www.UHCRetiree.com
H2802	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	St Louis Area		St Louis Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	806	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	St Louis Area		St Louis Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	807	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Springfield Area		Springfield Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCRetiree.com	www.UHCRetiree.com	www.UHCRetiree.com
H2802	808	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Springfield Area		Springfield Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2802	809	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Springfield Area		Springfield Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H2815	001	0	2021	20	Senior CommUnity Care of Colorado (PACE)	Senior CommUnity Care of Colorado		Senior CommUnity Care of Colorado	1	3	0									11485 Highway 65		Eckert	CO	81418		csimmers@voa.org	kehowell@voa.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorcommunitycare.org	0	0	1			0					3	0	0		www.voa.org	www.voa.org
H2815	002	0	2021	20	Senior CommUnity Care of Colorado (PACE)	Senior CommUnity Care of Colorado		Senior CommUnity Care of Colorado	1	3	0									2377 Robins Way		Montrose	CO	81401		csimmers@voa.org	kehowell@voa.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorcommunitycare.org	0	0	1			0					3	0	0		www.voa.org	www.voa.org
H2816	013	0	2021	09	WellCare Today's Options Premier Plus 250A (PFFS)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	019	0	2021	09	WellCare Today's Options Premier Plus 650B (PFFS)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	037	0	2021	09	WellCare Today's Options Premier 200 (PFFS)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	038	0	2021	09	WellCare Today's Options Premier 300 (PFFS)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	039	0	2021	09	WellCare Today's Options Premier 200 (PFFS)	Select counties in ME		Select counties in ME	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	040	0	2021	09	WellCare Today's Options Premier 300 (PFFS)	Select counties in ME		Select counties in ME	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	801	0	2021	09	Today's Options PFFS - MA Group Plan (PFFS)	National		National	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	802	0	2021	09	Today's Options PFFS - MAPD Group Plan (PFFS)	National		National	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2816	803	0	2021	09	Today's Options PFFS - MAPD Group Plan - NCY (PFFS)	National		National	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H2825	001	0	2021	01	Mary Washington Medicare Advantage Complete (HMO)	Greater Fredericksburg Region		Greater Fredericksburg Region	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mwmaplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mwmaplan.com	www.mwmaplan.com	www.mwmaplan.com
H2825	002	0	2021	01	Mary Washington Medicare Advantage Rewards (HMO)	Greater Fredericksburg Region		Greater Fredericksburg Region	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mwmaplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mwmaplan.com	www.mwmaplan.com	www.mwmaplan.com
H2825	801	0	2021	01	EGWP MAPD Calendar year (HMO)	Greater Fredericksburg Region		Greater Fredericksburg Region	1	3	1	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mwmaplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mwmaplan.com	www.mwmaplan.com	www.mwmaplan.com
H2825	802	0	2021	01	EGWP MAPD Non-Calendar year (HMO)	Greater Fredericksburg Region		Greater Fredericksburg Region	1	3	1	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mwmaplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mwmaplan.com	www.mwmaplan.com	www.mwmaplan.com
H2829	001	0	2021	01	Innovation Health-Aetna Medicare Connect (HMO)	Fairfax County and Surrounding Area		Fairfax County and Surrounding Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.innovationhealthmedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.innovationhealthmedicare.com/findprovider	www.innovationhealthmedicare.com/findpharmacy	www.innovationhealthmedicare.com/formulary
H2829	002	0	2021	01	Innovation Health-Aetna Medicare Eagle (HMO)	Fairfax County and Surrounding Area		Fairfax County and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.innovationhealthmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.innovationhealthmedicare.com/findprovider	www.innovationhealthmedicare.com	www.innovationhealthmedicare.com
H2835	001	0	2021	20	Thome PACE (PACE)	Jackson, Lenawee, and Hillsdale Counties		Jackson, Lenawee, and Hillsdale Counties	1	3	0									Susan Decker, Thome PACE	2282 Springport Rd	Jackson	MI	49202		sdecker@thomepace.org	sdecker@thomepace.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.thomepace.org	0	0	1			0					3	0	0	www.thomepace.org	www.hometownpharmacy.com	www.thomepace.org
H2835	002	0	2021	20	Thome PACE Medicare Only (PACE)	Jackson, Lenawee, and Hillsdale County		Jackson, Lenawee, and Hillsdale County	1	3	0									Susan Decker, Thome PACE	2282 Springport RD	Jackson	MI	49202		sdecker@thomepace.org	sdecker@thomepace.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.thomepace.org	0	0	1			0					3	0	0	www.thomepace.org	www.hometownpharmacy.com	www.thomepace.org
H2836	005	0	2021	04	Anthem MediBlue Access Select (PPO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265				P.O. Box 659403		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H2836	801	0	2021	04	Anthem MediBlue Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H2853	001	0	2021	01	Ascension Complete Saint Thomas Reward (HMO)	10 counties in central Tennessee		10 counties in central Tennessee	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ascensioncomplete.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $390.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $390.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/tn-findadoctor	ascensioncomplete.com/tn-findadoctor	ascensioncomplete.com/tn-formulary
H2853	002	0	2021	01	Ascension Complete Saint Thomas Secure (HMO)	10 counties in central Tennessee		10 counties in central Tennessee	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/tn-findadoctor	ascensioncomplete.com/tn-findadoctor	ascensioncomplete.com/tn-formulary
H2879	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H2882	003	0	2021	20	PACE Central Michigan (PACE)	Central Michigan		Central Michigan	1	3	0									1750 E Bellows		Mount Pleasant	MI	48858		tmcintyre@pacecmi.org	tmcintyre@pacecmi.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacecmi.org	0	0	1			0					3	0	0		https://hometownpharmacy.com/	N/A
H2882	004	0	2021	20	PACE Central Michigan (PACE)	Central Michigan		Central Michigan	1	3	0									1750 E Bellows		Mount Pleasant	MI	48858		tmcintyre@pacecmi.org	tmcintyre@pacecmi.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacecmi.org	0	0	1			0					3	0	0		https://hometownpharmacy.com/	N/A
H2915	001	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Western PA Counties		Western PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	002	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Southeastern PA Counties		Southeastern PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	003	0	2021	01	Allwell Medicare (HMO)	Western PA Counties		Western PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	007	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Central PA Counties		Central PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	010	0	2021	01	Allwell Medicare Simple (HMO)	Western PA Counties		Western PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	011	0	2021	01	Allwell Medicare Complement (HMO)	Statewide		Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	012	0	2021	01	Allwell Medicare Boost (HMO)	Western PA Counties		Western PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	013	0	2021	01	Allwell Medicare Simple (HMO)	Southeast PA Counties		Southeast PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	014	0	2021	01	Allwell Medicare Boost (HMO)	Southeast PA Counties		Southeast PA Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	015	2	2021	01	Allwell Medicare (HMO)	North, South Central & Southeast PA Counties		North & South Central PA	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	015	3	2021	01	Allwell Medicare (HMO)	North, South Central & Southeast PA Counties		Southeast Pennsylvania	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	801	0	2021	01	Allwell Group (HMO)	Pennsylvania		Pennsylvania	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	802	0	2021	01	Allwell Group (HMO)	Pennsylvania		Pennsylvania	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2915	803	0	2021	01	Allwell Group (HMO)	Pennsylvania		Pennsylvania	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pahealthwellness.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/findadoctor	allwell.pahealthwellness.com/formulary
H2926	001	0	2021	01	Prime Health Complete (HMO D-SNP)	Northern, west central, and southwestern Minnesota		Northern, west central, and southwestern Minnesota	1	0	0	3905 Dakota Street		Alexandria	MN	56308		matt.magnuson@primewest.org	matt.magnuson@primewest.org	3905 Dakota Street		Alexandria	MN	56308		matt.magnuson@primewest.org	matt.magnuson@primewest.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.primewest.org/phc	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.primewest.org/find-a-health-care-provider	https://primewest.org/drug-search	https://primewest.org/pharmacy-search
H2936	001	0	2021	20	LifeCircles (PACE)	Muskegon, Ottawa, Allegan		Muskegon, Ottawa, Allegan	1	3	0									560 Seminole Rd		Muskegon	MI	49444		lreynolds@lifecircles-pace.org	lreynolds@lifecircles-pace.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http:www.lifecircles-pace.org	0	0	1			0					3	0	0		www.lifecircles-pace.org	www.lifecircles-pace.org
H2936	002	0	2021	20	002 - Medicare Only (PACE)	002 - Medicare Only		002 - Medicare Only	1	3	0									560 Seminole Rd		Muskegon	MI	49444		lreynolds@lifecircles-pace.org	lreynolds@lifecircles-pace.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http:www.lifecircles-pace.org	0	0	1			0					3	0	0		www.lifecircles-pace.org	www.lifecircles-pace.org
H2937	001	0	2021	20	Senior LIFE Greensburg Dual Eligible (PACE)	Westmoreland County		Westmoreland County	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H2937	002	0	2021	20	Senior LIFE Greensburg Medicare Only (PACE)	Westmoreland County		Westmoreland County	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Seniorlifegreensburg.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H2941	001	0	2021	20	Sentara Senior Community Care Dual (PACE)	South Hampton Roads Area		South Hampton Roads Area	1	3	0									863 Glenrock Rd	Suite 200	Norfolk	VA	23502		mbford2@sentara.com	mbford2@sentara.com	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sentara.com/pace	0	0	1			0					3	0	0		www.sentara.com	www.sentara.com
H2941	002	0	2021	20	Sentara Senior Community Care Private (PACE)	South Hampton Roads area		South Hampton Roads area	1	3	0									863 Glenrock Rd	Suite 200	Norfolk	VA	23502		mbford2@sentara.com	mbford2@sentara.com	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sentara.com/pace	0	0	1			0					3	0	0		www.sentara.com	www.sentara.com
H2944	013	0	2021	09	Humana Gold Choice H2944-013 (PFFS)	Select Counties in KS, MO and OK		Select Counties in KS, MO and OK	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2944	114	0	2021	09	Humana Gold Choice H2944-114 (PFFS)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2944	197	0	2021	09	Humana Gold Choice H2944-197 (PFFS)	Select Counties in KS, MO and OK		Select Counties in KS, MO and OK	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2			0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H2960	009	0	2021	01	Senior Care Plus Patriot Plan (HMO)	Washoe, Carson City Counties, NV	Senior Care Plus Patriot Plan (HMO)	Washoe, Carson City Counties, NV	1	0	0	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com									5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	012	0	2021	01	Senior Care Plus Essential plan (HMO)	Washoe, Carson City Counties, NV	Senior Care Plus Essential plan (HMO)	Washoe, Carson City Counties, NV	1	0	0	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	018	0	2021	01	Senior Care Plus Select Plan (HMO)	Washoe, Carson City Counties, NV	Senior Care Plus Select Plan (HMO)	Washoe, Carson City Counties, NV	1	0	0	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	019	0	2021	01	Senior Care Plus Complete Plan (HMO)	Clark and Nye Counties	Senior Care Plus Complete Plan (HMO)	Clark and Nye Counties	1	0	0	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	021	0	2021	01	Senior Care Plus Comprehensive plan (HMO)	Clark County Nv	Senior Care Plus Comprehensive plan (HMO)	Clark County Nv	1	0	0	10315 Professional Circle		Reno	NV	89521		customer_service@hometownhealth.com	customer_service@hometownhealth.com	10315 Professional Circle		Reno	NV	89521		customer_service@hometownhealth.com	customer_service@hometownhealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	022	0	2021	01	Senior Care Plus Encompass Plan (HMO C-SNP)	Clark, NV County	Senior Care Plus Encompass Plan (HMO C-SNP)	Clark, NV County	1	0	0	10315 Professional Circle		reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	10315 Professional Circle		reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	023	0	2021	01	Renown Preferred Plan by Senior Care Plus (HMO)	Washoe, Carson City Counties, NV	Renown Preferred Plan by Senior Care Plus (HMO)	Washoe, Carson City Counties, NV	1	0	0	10315 Professional Cir		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	10315 Professional Cir		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2960	803	0	2021	01	Senior Care Plus: Value Group Plan (HMO)	State of Nevada	Senior Care Plus: Value Group Plan (HMO)	State of Nevada	1	3	1	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	10315 Professional Circle		Reno	NV	89521		Customer_Service@hometownhealth.com	Customer_Service@hometownhealth.com	5107002000207002000307002000407002000507002000607002000707002000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SeniorCarePlus.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.SeniorCarePlus.com	www.SeniorCarePlus.com	www.SeniorCarePlus.com
H2962	001	0	2021	01	Premier by Ultimate (HMO)	Hernando County		Hernando County	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	011	0	2021	01	Premier by Ultimate (HMO)	Pinellas and Hillsborough Counties, FL		Pinellas and Hillsborough Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	012	0	2021	01	Premier Plus by Ultimate (HMO)	Pinellas and Hillsborough Counties, FL		Pinellas and Hillsborough Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	013	3	2021	01	Premier by Ultimate (HMO)	Citrus and Pasco Counties, FL		Pasco County	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	013	4	2021	01	Premier by Ultimate (HMO)	Citrus and Pasco Counties, FL		Citrus County	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	014	1	2021	01	Premier Plus by Ultimate (HMO)	Citrus, Hernando and Pasco Counties, FL		Hernando and Pasco Counties	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	014	2	2021	01	Premier Plus by Ultimate (HMO)	Citrus, Hernando and Pasco Counties, FL		Citrus County	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	016	0	2021	01	Premier Plus by Ultimate (HMO)	Marion, Lake and Sumter Counties, FL		Marion, Lake and Sumter Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	019	1	2021	01	Advantage Care by Ultimate (HMO C-SNP)	Hernando and Pasco Counties in Florida		Hernando County, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	019	2	2021	01	Advantage Care by Ultimate (HMO C-SNP)	Hernando and Pasco Counties in Florida		Pasco County, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	021	0	2021	01	Advantage Care by Ultimate (HMO C-SNP)	Citrus County, FL		Citrus County, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	022	0	2021	01	Advantage Care CHF by Ultimate (HMO C-SNP)	Citrus County, FL		Citrus County, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	023	0	2021	01	Advantage Care COPD by Ultimate (HMO C-SNP)	Citrus County, FL		Citrus County, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	024	0	2021	01	Advantage Care CHF by Ultimate (HMO C-SNP)	Hernando and Pasco Counties, FL		Hernando and Pasco Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	025	0	2021	01	Advantage Care COPD by Ultimate (HMO C-SNP)	Hernando and Pasco Counties, FL		Hernando and Pasco Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	026	0	2021	01	Advantage Care by Ultimate (HMO C-SNP)	Hillsborough and Pinellas Counties, FL		Hillsborough and Pinellas Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	027	0	2021	01	Advantage Care COPD by Ultimate (HMO C-SNP)	Hillsborough County, Pinellas County, FL		Hillsborough County, Pinellas County, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	028	0	2021	01	Premier by Ultimate (HMO)	Marion, Lake and Sumter Counties, FL		Marion, Lake and Sumter Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	029	0	2021	01	Advantage Care by Ultimate (HMO C-SNP)	Marion, Lake and Sumter Counties, FL		Marion, Lake and Sumter Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	030	0	2021	01	Advantage Care COPD by Ultimate (HMO C-SNP)	Marion, Lake, and Sumter Counties, FL		Marion, Lake, and Sumter Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	031	0	2021	01	Premier by Ultimate (HMO)	Indian River and St. Lucie Counties, FL		Indian River and St. Lucie Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	032	0	2021	01	Premier Plus by Ultimate (HMO)	Indian River and St. Lucie Counties, FL		Indian River and St. Lucie Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	033	0	2021	01	Advantage Care by Ultimate (HMO C-SNP)	Indian River and St. Lucie Counties, FL		Indian River and St. Lucie Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2962	034	0	2021	01	Advantage Care COPD by Ultimate (HMO C-SNP)	Indian River and St. Lucie Counties, FL		Indian River and St. Lucie Counties, FL	1	0	0	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2713 Forest Road		Spring Hill	FL	34606		futuremembers@ulthp.com	memberadvocate@ulthp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.chooseultimate.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.chooseultimate.com	www.chooseultimate.com	www.chooseultimate.com
H2986	001	0	2021	01	Stanford Health Care Advantage - Platinum (HMO)	Santa Clara County		Santa Clara County	1	0	0	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	002	0	2021	01	Stanford Health Care Advantage - Gold (HMO)	Santa Clara County		Santa Clara County	1	0	0	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	004	0	2021	01	Stanford Health Care Advantage - Platinum (HMO)	Alameda County		Alameda County	1	0	0	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	006	0	2021	01	Stanford Health Care Advantage - Platinum (HMO)	San Mateo County		San Mateo County	1	0	0	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	007	0	2021	01	Stanford Health Care Advantage - Gold (HMO)	Alameda and San Mateo Counties		Alameda and San Mateo Counties	1	0	0	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	801	0	2021	01	Stanford Health Care Advantage EGWP MAPD calendar (HMO)	Alameda, Santa Clara, San Mateo counties		Alameda, Santa Clara, San Mateo counties	1	3	1	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	802	0	2021	01	Stanford Health Care Advantage EGWP MAPD non-CY (HMO)	Alameda, Santa Clara, San Mateo counties		Alameda, Santa Clara, San Mateo counties	1	3	1	PO Box 5904		Troy	MI	48007				PO Box 5904		Troy	MI	48007				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2986	803	0	2021	01	Stanford Health Care Advantage EGWP MA only CY (HMO)	Alameda, Santa Clara, San Mateo counties		Alameda, Santa Clara, San Mateo counties	1	3	1	PO Box 5904		Troy	MI	48007												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.StanfordHealthCareAdvantage.org	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org	www.StanfordHealthCareAdvantage.org
H2992	001	0	2021	20	Senior LIFE Washington Dual Eligible (PACE)	Washington and Greene Counties		Washington and Greene Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	None
H2992	002	0	2021	20	Senior LIFE Washington Medicare Only (PACE)	Washington and Greene Counties		Washington and Greene Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifewashington.com	0	0	1			0					3	0	0		http://granerx.com/	None
H2992	003	0	2021	20	Senior LIFE Uniontown Dual Eligible (PACE)	Fayette County		Fayette County	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifeuniontown.com	0	0	1			0					3	0	0		http://granerx.com/	None
H2992	004	0	2021	20	Senior LIFE Uniontown Medicare Only (PACE)	Fayette County		Fayette County	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600001200700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifeuniontown.com	0	0	1			0					3	0	0		http://granerx.com/	None
H3015	001	0	2021	01	Shared Health Dual Plus (HMO D-SNP)	Mississippi		Mississippi	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.sharedhealthms.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.sharedhealthms.com	www.sharedhealthms.com	www.sharedhealthms.com
H3047	001	0	2021	04	WellCare Premier (PPO)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H3047	002	0	2021	04	Wellcare Absolute (PPO)	Select counties in LA		Select counties in LA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H3060	001	0	2021	20	VieCare Butler, LLC dba LIFE Butler County (PACE)	Butler County		Butler County	1	3	0									231 West Diamond Street		Butler	PA	16001				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lutheranseniorlife.org	0	0	1			0					3	0	0		www.lutheranseniorlife.org	www.lutheranseniorlife.org
H3060	002	0	2021	20	VieCare Butler, LLC dba LIFE Butler County (PACE)	Butler County		Butler County	1	3	0									231 West Diamond Street		Butler	PA	16001				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lutheranseniorlife.org	0	0	1			0					3	0	0		www.lutheranseniorlife.org	www.lutheranseniorlife.org
H3071	002	0	2021	01	Clear Spring Health Community Advantage Plan (HMO)	Rockford Area, Chicago Area		Rockford Area, Chicago Area	1	0	0	P.O. BOX 278530		miramar	FL	33027				P.O. BOX 278530		miramar	FL	33027				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ccaillinois.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.ccaillinois.com/medicare	www.ccaillinois.com/medicare	www.ccaillinois.com/medicare
H3071	003	0	2021	02	Clear Spring Health Community Flex Plan (HMO-POS)	Rockford Area, Chicago Area		Rockford Area, Chicago Area	1	0	0	P.O. BOX 278530		Miramar	FL	33027				P.O. BOX 278530		Miramar	FL	33027				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ccaillinois.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.ccaillinois.com/medicare	www.ccaillinois.com/medicare	www.ccaillinois.com/medicare
H3084	001	0	2021	20	ICHS PACE - Dual Eligible (PACE)	Parts of King County		Parts of King County	1	3	0									PO Box 3007		Seattle	WA	98114				5000000000208001800308001800408001800508001800608001800000000000	5000000000208001800308001800408001800508001800608001800000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ichsPACE.org	0	0	1			0					3	0	0		NA	NA
H3084	002	0	2021	20	ICHS PACE - Medicare Only (PACE)	Parts of King County		Parts of King County	1	3	0									PO Box 3007		Seattle	WA	98114				5108001800208001800308001800408001800508001800608001800708001800	5108001800208001800308001800408001800508001800608001800708001800	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ichsPACE.org	0	0	1			0					3	0	0		NA	NA
H3113	001	0	2021	01	UnitedHealthcare Nursing Home Plan (HMO I-SNP)	Northern and Central New Jersey		Northern and Central New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3113	005	0	2021	01	UnitedHealthcare Dual Complete ONE (HMO D-SNP)	Select counties in New Jersey		Select counties in New Jersey	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3113	008	0	2021	02	UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP)	Lane County of Oregon		Lane County of Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3113	009	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select counties in Pennsylvania		Select counties in Pennsylvania	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHC.com/PADual	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHC.com/PADual	www.UHC.com/PADual	www.UHC.com/PADual
H3113	010	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3113	011	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Kent, New Castle, and Sussex Counties		Kent, New Castle, and Sussex Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3132	001	0	2021	01	PHP (HMO C-SNP)	Broward, Miami-Dade and Duval Counties, Florida	PHP (HMO C-SNP)	Broward, Miami-Dade and Duval Counties, Florida	1	0	0	P.O. Box 46160		Los Angeles	CA	90046		php@positivehealthcare.org	php@positivehealthcare.org	P.O. Box 46160		Los Angeles	CA	90046		php@positivehealthcare.org	php@positivehealthcare.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.php-fl.org	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.php-fl.org/provider-find	www.php-fl.org/provider-find	www.php-fl.org/for-members/drug-benefit/formulary
H3146	001	0	2021	01	Aetna Medicare Value Plan (HMO)	Charlotte NC and Surrounding Area		Charlotte NC and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	002	0	2021	01	Aetna Medicare Assure Plan (HMO D-SNP)	Triangle North Carolina Area		Triangle North Carolina Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	003	0	2021	01	Aetna Medicare Assure Plan (HMO D-SNP)	Triad North Carolina Area		Triad North Carolina Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	004	0	2021	01	Aetna Medicare Value Plan (HMO)	Triangle North Carolina Area		Triangle North Carolina Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	005	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Western North Carolina		Western North Carolina	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	006	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Greensboro, Winston-Salem NC and Surrounding Area		Greensboro, Winston-Salem NC and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	007	0	2021	01	Aetna Medicare Prime (HMO)	Triad and Piedmont Area NC		Triad and Piedmont Area NC	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	008	0	2021	01	Aetna Medicare Assure Plan (HMO D-SNP)	Charlotte Metro North Carolina		Charlotte Metro North Carolina	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	009	0	2021	01	Aetna Medicare Assure Plan (HMO D-SNP)	Western North Carolina		Western North Carolina	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	010	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Charlotte Metro North Carolina		Charlotte Metro North Carolina	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	011	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Upstate South Carolina		Upstate South Carolina	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	012	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Middle Tennessee		Middle Tennessee	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	013	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Memphis TN and Surrounding Area		Memphis TN and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	801	0	2021	01	Aetna Medicare Plan (HMO)	North Carolina		North Carolina	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3146	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	North Carolina		North Carolina	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	022	0	2021	01	Aetna Medicare Explorer Premier (HMO)	SNJ Counties: AL, BR, CM, CP, CU, GL, ON, SM		SNJ Counties: AL, BR, CM, CP, CU, GL, ON, SM	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	045	0	2021	01	Aetna Medicare Eagle (HMO)	New Jersey Counties: All		New Jersey Counties: All	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	048	0	2021	01	Aetna Medicare Explorer Premier Plus (HMO)	Northern New Jersey		Northern New Jersey	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	080	0	2021	01	Aetna Medicare Prime Value (HMO)	Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR		Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	082	0	2021	01	Aetna Medicare Explorer Value (HMO)	Southern NJ, Middlesex and Monmouth Counties		Southern NJ, Middlesex and Monmouth Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	084	0	2021	01	Aetna Medicare Explorer Elite (HMO)	Northern and Southern NJ		Northern and Southern NJ	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	088	0	2021	01	Aetna Medicare Value 2 (HMO)	New Jersey Counties: All		New Jersey Counties: All	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	092	0	2021	01	Aetna Medicare Explorer Elite 2 (HMO)	NNJ Counties: BR, ES, HD, MR, MX, MN, MO, PS, UN		NNJ Counties: BR, ES, HD, MR, MX, MN, MO, PS, UN	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	801	0	2021	01	Aetna Medicare Plan (HMO)	New Jersey		New Jersey	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3152	804	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	New Jersey		New Jersey	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3154	004	0	2021	01	Horizon Medicare Blue Value w/Rx (HMO)	Cape May, Hudson, Salem, Union, Warren		Cape May, Hudson, Salem, Union, Warren	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	013	0	2021	01	Horizon Medicare Blue Value (HMO)	Cape May, Hudson, Salem, Union, Warren		Cape May, Hudson, Salem, Union, Warren	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	022	0	2021	01	Horizon Medicare Blue Choice w/Rx (HMO)	11 Counties Throughout New Jersey		11 Counties Throughout New Jersey	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	029	0	2021	01	Horizon Medicare Blue Advantage (HMO)	Ocean and Monmouth		Ocean and Monmouth	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	030	0	2021	01	Horizon Medicare Blue Advantage (HMO)	Bergen Essex Hudson Mercer Middlesex Union		Bergen Essex Hudson Mercer Middlesex Union	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	031	0	2021	01	Horizon Medicare Blue Advantage (HMO)	Hunterdon, Somerset, Sussex, Warren		Hunterdon, Somerset, Sussex, Warren	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	032	0	2021	01	Horizon Medicare Blue Advantage (HMO)	Atlantic, Cumberland, Morris		Atlantic, Cumberland, Morris	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	033	0	2021	02	Horizon Medicare Blue Select (HMO-POS)	Union County		Union County	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H3154	801	0	2021	02	Horizon Medicare Blue Access Group (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East, PP- 12F		Newark	NJ	07105												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.HorizonBlue.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com/	www.horizonblue.com/ma-pharmacy-search	medicare.horizonblue.com/medicare-advantage-health-insurance-new-jersey-formulary-drug-search
H3154	802	0	2021	02	Horizon Medicare Blue Access Group w/Rx (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East, PP- 12F		Newark	NJ	07105				3 Penn Plaza East, PP- 12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.HorizonBlue.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com/	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJHMOG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJHMOG/en/find-medicine.html
H3154	811	0	2021	02	Horizon Medicare Advantage HMO10 (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East, PP- 12F		Newark	NJ	07105												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.HorizonBlue.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com/	www.horizonblue.com/ma-pharmacy-search	medicare.horizonblue.com/medicare-advantage-health-insurance-new-jersey-formulary-drug-search
H3154	812	0	2021	02	Horizon Medicare Blue Access Group w/Rx Value (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East, PP- 12F		Newark	NJ	07105				3 Penn Plaza East, PP- 12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.HorizonBlue.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com/	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJHMOG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJHMOG/en/find-medicine.html
H3170	002	0	2021	02	Blue Cross Blue Shield Nebraska MA Choice (HMO-POS)	Omaha/ Lincoln Metro Area and Central Nebraska		Omaha/ Lincoln Metro Area and Central Nebraska	1	0	0	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				4000000000207002000307002000407002000507002000607002000000000000	4107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https//Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H3170	003	1	2021	01	Blue Cross Blue Shield Nebraska MA Core (HMO)	Omaha/Lincoln Metro Area and Central Nebraska		Metro Area	1	0	0	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				4000000000207002000307002000407002000507002000607002000000000000	4107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H3170	003	2	2021	01	Blue Cross Blue Shield Nebraska MA Core (HMO)	Omaha/Lincoln Metro Area and Central Nebraska		Central Nebraska	1	0	0	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				4000000000207002000307002000407002000507002000607002000000000000	4107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H3192	001	0	2021	01	Aetna Medicare Prime (HMO)	Chicagoland		Chicagoland	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	002	0	2021	01	Aetna Medicare Premier (HMO)	Midland County		Midland County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	003	0	2021	01	Aetna Medicare Premier (HMO)	Southeast Michigan		Southeast Michigan	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	004	0	2021	01	Aetna Medicare Prime (HMO)	Ft Wayne and Northeast Indiana area		Ft Wayne and Northeast Indiana area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	005	0	2021	01	Aetna Medicare Prime (HMO)	Northwest Indiana area		Northwest Indiana area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	006	0	2021	01	Aetna Medicare Prime (HMO)	Indianapolis and Central Indiana area		Indianapolis and Central Indiana area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	007	0	2021	01	Aetna Medicare Assure Premier (HMO D-SNP)	Southeast Michigan area		Southeast Michigan area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	801	0	2021	01	Aetna Medicare Plan (HMO)	Illinois and Michigan		Illinois and Michigan	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3192	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Illinois and Michigan		Illinois and Michigan	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3204	001	0	2021	01	Presbyterian Senior Care Plan 2 with Rx (HMO)	Greater Albuquerque Area, Rio Arriba and Santa Fe		Greater Albuquerque Area, Rio Arriba and Santa Fe	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	007	0	2021	01	Presbyterian Senior Care Plan 3 with Rx (HMO)	Greater Albuquerque Area, Rio Arriba and Santa Fe		Greater Albuquerque Area, Rio Arriba and Santa Fe	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	008	0	2021	01	Presbyterian Senior Care Plan 1 (HMO)	Greater Albuquerque Area, Rio Arriba and Santa Fe		Greater Albuquerque Area, Rio Arriba and Santa Fe	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	013	4	2021	01	Presbyterian Dual Plus (HMO D-SNP)	State of New Mexico		Central New Mexico	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		nchavez16@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		nchavez16@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	013	5	2021	01	Presbyterian Dual Plus (HMO D-SNP)	State of New Mexico		Rural New Mexico	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		nchavez16@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		nchavez16@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	801	0	2021	02	Pres Senior Care Emp Group Plan 2 with Rx (HMO-POS)	Greater Albuquerque Area, Rio Arriba and Santa Fe		Greater Albuquerque Area, Rio Arriba and Santa Fe	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phs.org/Medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	802	0	2021	02	Pres Senior Care Emp Group Plan 1 (HMO-POS)	Greater Albuquerque Area, Rio Arriba and Santa Fe		Greater Albuquerque Area, Rio Arriba and Santa Fe	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phs.org/Medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	803	0	2021	02	Pres Senior Care Emp Group Plan 2 w/ Rx NC (HMO-POS)	Greater Albuquerque Area, Rio Arriba and Santa Fe		Greater Albuquerque Area, Rio Arriba and Santa Fe	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phs.org/Medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	808	0	2021	02	Presbyterian Senior Care Emp Group Plan 5 (HMO-POS)	State of New Mexico		State of New Mexico	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phs.org/Medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	809	0	2021	02	Presbyterian Senior Care Emp Group Plan 6 (HMO-POS)	State of New Mexico		State of New Mexico	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phs.org/Medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3204	810	0	2021	02	Presbyterian Senior Care Emp Group Plan 5 NC (HMO-POS)	State of New Mexico		State of New Mexico	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phs.org/Medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3206	001	0	2021	04	Presbyterian MediCare PPO Plan 2 with Rx (PPO)	State of New Mexico		State of New Mexico	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3206	003	0	2021	04	Presbyterian MediCare PPO Plan 1 (PPO)	State of New Mexico		State of New Mexico	1	0	0	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3206	801	0	2021	04	Pres MediCare PPO Emp Group Plan 2 with Rx (PPO)	State of New Mexico		State of New Mexico	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3206	802	0	2021	04	Pres Medicare PPO Employer Group Plan 1 (PPO)	State of New Mexico		State of New Mexico	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3206	803	0	2021	04	Pres MediCare PPO Empl Group Plan 2 +Rx NC (PPO)	State of New Mexico		State of New Mexico	1	3	1	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	P.O. Box 27489		Albuquerque	NM	87125		jdecker@phs.org	kgarcia3@phs.org	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.phs.org/Medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	https://www.phs.org/doctors-services/Pages/find-a-doctor.aspx	www.phs.org/Medicare	www.phs.org/Medicare
H3213	011	0	2021	01	CareSource Advantage (HMO)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ky/plans/medicare/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $30.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $30.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ky/plans/medicare/benefits-services/pharmacy/drug-formulary/
H3213	012	0	2021	01	CareSource Advantage (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ky/plans/medicare/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ky/plans/medicare/benefits-services/pharmacy/drug-formulary/
H3213	013	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ky/plans/medicare/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ky/plans/medicare/benefits-services/pharmacy/drug-formulary/
H3213	014	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ky/plans/medicare/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ky/plans/medicare/benefits-services/pharmacy/drug-formulary/
H3213	015	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	http://www.caresource.com/ky/plans/dsnp/	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ky/plans/dsnp/pharmacy/drug-formulary/
H3213	016	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	http://www.caresource.com/ky/plans/dsnp/	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ky/plans/dsnp/pharmacy/drug-formulary/
H3219	001	0	2021	04	Allina Health Aetna Medicare Discover Plus (PPO)	Twin Cities Metro and Select MN Counties		Twin Cities Metro and Select MN Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AllinaHealthAetnaMedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AllinaHealthAetnaMedicare.com/findprovider	www.AllinaHealthAetnaMedicare.com/findpharmacy	www.AllinaHealthAetnaMedicare.com/formulary
H3219	002	0	2021	04	Allina Health Aetna Medicare Discover Premier (PPO)	Twin Cities Metro and Select MN Counties		Twin Cities Metro and Select MN Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AllinaHealthAetnaMedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AllinaHealthAetnaMedicare.com/findprovider	www.AllinaHealthAetnaMedicare.com/findpharmacy	www.AllinaHealthAetnaMedicare.com/formulary
H3219	003	0	2021	04	Allina Health Aetna Medicare Discover Grand (PPO)	Twin Cities Metro and Select MN Counties		Twin Cities Metro and Select MN Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AllinaHealthAetnaMedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.AllinaHealthAetnaMedicare.com/findprovider	www.AllinaHealthAetnaMedicare.com/findpharmacy	www.AllinaHealthAetnaMedicare.com/formulary
H3219	004	0	2021	04	Allina Health Aetna Medicare Discover Elite (PPO)	Twin Cities Metro and Select MN Counties		Twin Cities Metro and Select MN Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AllinaHealthAetnaMedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.AllinaHealthAetnaMedicare.com/findprovider	www.AllinaHealthAetnaMedicare.com/findpharmacy	www.AllinaHealthAetnaMedicare.com/formulary
H3219	005	0	2021	04	Allina Health Aetna Medicare Discover Value (PPO)	Twin Cities Metro and Select MN Counties		Twin Cities Metro and Select MN Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.AllinaHealthAetnaMedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.AllinaHealthAetnaMedicare.com/findprovider	www.AllinaHealthAetnaMedicare.com	www.AllinaHealthAetnaMedicare.com
H3219	801	0	2021	04	Allina Health Aetna Medicare Plan (PPO)	Minnesota		Minnesota	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3219	802	0	2021	04	Allina Health Aetna Medicare w/Rx Plan (PPO)	Minnesota		Minnesota	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3237	001	0	2021	48	Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)	Los Angeles County	Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)	Los Angeles County	1	0	0	4349 Easton Way	Suite 300	Columbus	OH	43219			Internet_response_team@healthnet.com	4349 Easton Way	Suite 300	Columbus	OH	43219			Internet_response_team@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.healthnet.com/calmediconnect	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	mmp.healthnetcalifornia.com/mmp/find-a-doctor.html	mmp.healthnetcalifornia.com/mmp/find-a-doctor.html	mmp.healthnetcalifornia.com/mmp/prescription-drug-part-d/formulary.html
H3237	002	0	2021	48	Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)	San Diego County	Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)	San Diego County	1	0	0	4349 Easton Way	Suite 300	Columbus	OH	43219			Internet_response_team@healthnet.com	4349 Easton Way	Suite 300	Columbus	OH	43219			Internet_response_team@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.healthnet.com/calmediconnect	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	mmp.healthnetcalifornia.com/mmp/find-a-doctor.html	mmp.healthnetcalifornia.com/mmp/find-a-doctor.html	mmp.healthnetcalifornia.com/mmp/prescription-drug-part-d/formulary.html
H3239	001	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	New Orleans and Surrounding Parishes		New Orleans and Surrounding Parishes	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3239	002	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Select Birmingham and Northern AL counties		Select Birmingham and Northern AL counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3239	003	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Select Counties in Montgomery and Mobile AL area		Select Counties in Montgomery and Mobile AL area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3239	005	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Northern Mississippi		Northern Mississippi	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3239	006	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Shreveport area		Shreveport area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3239	007	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Lafayette, Alexandria and Lake Charles area		Lafayette, Alexandria and Lake Charles area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3240	013	0	2021	01	Amerivantage Dual Coordination (HMO D-SNP)	Eastern and Central New Jersey	Amerivantage Dual Coordination (HMO D-SNP)	Eastern and Central New Jersey	1	0	0	Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H3240	017	0	2021	02	Amerivantage ESRD Care (HMO-POS C-SNP)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.amerigroup.com/medicare/	1	4	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H3240	021	0	2021	01	Amerivantage Balance (HMO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H3240	022	0	2021	01	Amerivantage Classic (HMO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830		mediblue@empireblue.com	mediblue@empireblue.com	Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H3240	024	0	2021	02	Amerivantage Dual Secure (HMO-POS D-SNP)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				Amerigroup New Jersey	101 Wood Ave South Suite 800	Iselin	NJ	08830				9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.amerigroup.com/medicare/	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H3251	002	0	2021	01	Blue Cross Medicare Advantage Select (HMO)	Greater New Mexico Area		Greater New Mexico Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/mapd	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluenm.com/mapd/providers	www.getbluenm.com/mapd/pharmacies	www.getbluenm.com/mapd/druglist
H3251	029	0	2021	01	Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)	New Mexico Counties		New Mexico Counties	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/dsnp	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.getbluenm.com/dsnp/providers	www.getbluenm.com/dsnp/pharmacies	www.getbluenm.com/dsnp/druglist
H3251	804	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	New Mexico Statewide		New Mexico Statewide	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluenm.com/mapd	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	getbluenm.com/mapd/providers	www.getbluenm.com/mapd/pharmacies	www.getbluenm.com/mapd/druglist
H3256	001	0	2021	04	UnitedHealthcare Dual Complete Choice LP (PPO D-SNP)	Select Counties for Georgia		Select Counties for Georgia	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30769		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3259	001	0	2021	01	BlueCare Plus (HMO D-SNP)	Tennessee		Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	bluecareplus.bcbst.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	bluecareplus.bcbst.com	bluecareplus.bcbst.com	bluecareplus.bcbst.com
H3259	002	0	2021	01	BlueCare Plus Choice (HMO D-SNP)	Tennessee		Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	bluecareplus.bcbst.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	bluecareplus.bcbst.com	bluecareplus.bcbst.com	bluecareplus.bcbst.com
H3276	001	0	2021	01	ConnectiCare Choice Dual (HMO D-SNP)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3276	002	0	2021	01	ConnectiCare Choice Dual Basic (HMO D-SNP)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3281	001	0	2021	04	Bright Advantage Health Dollars (PPO)	Daytona Beach Area		Daytona Beach Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3281	003	0	2021	04	Bright Advantage Choice (PPO)	Orlando Area		Orlando Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3281	005	0	2021	04	Bright Advantage Part B Savings (PPO)	Palm Beach Area		Palm Beach Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3281	007	0	2021	04	Bright Advantage Part B Savings (PPO)	Fort Lauderdale Area		Fort Lauderdale Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3281	009	0	2021	04	Bright Advantage Part B Savings (PPO)	Daytona Beach Area		Daytona Beach Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3281	010	0	2021	04	Bright Advantage Part B Savings (PPO)	Orlando Area		Orlando Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3281	011	0	2021	04	Bright Advantage Part B Savings (PPO)	Central Florida		Central Florida	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3288	001	0	2021	04	Aetna Medicare Choice Plan (PPO)	Bexar and Comal counties		Bexar and Comal counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	002	0	2021	04	Aetna Medicare Choice II Plan (PPO)	Dallas and Surrounding Counties		Dallas and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	003	0	2021	04	Aetna Medicare Choice Plan (PPO)	Harris County		Harris County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	004	0	2021	04	Aetna Medicare Choice Plan (PPO)	Travis and Williamson Counties		Travis and Williamson Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	005	0	2021	04	Aetna Medicare Choice Plan (PPO)	South Texas Non Metro counties		South Texas Non Metro counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	006	0	2021	04	Aetna Medicare Choice Plan (PPO)	Southeast Non Metro		Southeast Non Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	007	0	2021	04	Aetna Medicare Choice Plan (PPO)	El Paso County		El Paso County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	008	0	2021	04	Aetna Medicare Choice Plan (PPO)	North Texas Non Metro counties		North Texas Non Metro counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	009	0	2021	04	Aetna Medicare Choice Plan (PPO)	Rio Grande Valley and Corpus Christi		Rio Grande Valley and Corpus Christi	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	010	0	2021	04	Aetna Medicare Plus Plan (PPO)	El Paso County		El Paso County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	011	0	2021	04	Aetna Medicare Choice Plan (PPO)	Panhandle Region		Panhandle Region	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	012	0	2021	04	Aetna Medicare Plus Plan (PPO)	Rio Grande Valley and Corpus Christi		Rio Grande Valley and Corpus Christi	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	013	0	2021	04	Aetna Medicare Plus Plan (PPO)	Bexar County		Bexar County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	015	0	2021	04	Aetna Medicare Plus Plan (PPO)	Dallas County		Dallas County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	016	0	2021	04	Aetna Medicare Choice Plan (PPO)	Dallas and Surrounding Counties		Dallas and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	017	0	2021	04	Aetna Medicare Freedom Preferred Plan (PPO)	Oklahoma City and Surrounding Counties		Oklahoma City and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	018	0	2021	04	Aetna Medicare Choice II Plan (PPO)	Southeast Non Metro		Southeast Non Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	019	0	2021	04	Aetna Medicare Freedom Preferred Plan (PPO)	Tulsa and Surrounding Counties		Tulsa and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	020	0	2021	04	Aetna Medicare Freedom Core Plan (PPO)	Rural Oklahoma		Rural Oklahoma	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	021	0	2021	04	Aetna Medicare Freedom Core Plan (PPO)	Tulsa and Surrounding Counties		Tulsa and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	022	0	2021	04	Aetna Medicare Plus Plan (PPO)	Travis and Williamson Counties		Travis and Williamson Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	023	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Albany Metro and Surrounding Counties		Albany Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	024	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Augusta Metro and Surrounding Counties		Augusta Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	025	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Central Georgia		Central Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	026	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Columbus Metro and Surrounding Counties		Columbus Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	027	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Macon Metro and Surrounding Counties		Macon Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	028	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Northeast Georgia		Northeast Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	029	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Northern Georgia		Northern Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	030	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Savannah Metro and Surrounding Counties		Savannah Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	031	0	2021	04	Aetna Medicare Freedom Plan (PPO)	South Georgia		South Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	032	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Hall County		Hall County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	033	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Cobb and Paulding Counties		Cobb and Paulding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	034	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Georgia Market		Georgia Market	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	035	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Floyd, Haralson and Polk Counties		Floyd, Haralson and Polk Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	036	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Albany Metro and Surrounding Counties		Albany Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	037	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Augusta Metro and Surrounding Counties		Augusta Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	038	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Central Georgia		Central Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	039	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Columbus Metro and Surrounding Counties		Columbus Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	040	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Macon Metro and Surrounding Counties		Macon Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	041	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Northeast Georgia		Northeast Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	042	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Northern Georgia		Northern Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	043	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	Savannah Metro and Surrounding Counties		Savannah Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	044	0	2021	04	Aetna Medicare Preferred Premium Plan (PPO)	South Georgia		South Georgia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	045	0	2021	04	Aetna Medicare Plus Plan (PPO)	Atlanta Metro and Surrounding Counties		Atlanta Metro and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	046	0	2021	04	Aetna Medicare Choice Plan (PPO)	Central Non Metro		Central Non Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	047	0	2021	04	Aetna Medicare Value Plan (PPO)	Harris County		Harris County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	048	0	2021	04	Aetna Medicare Choice II Plan (PPO)	Central Non Metro		Central Non Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	049	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Dallas County		Dallas County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	050	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Harris County		Harris County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	051	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Tulsa		Tulsa	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3288	801	0	2021	04	Aetna Medicare Plan (PPO)	Multi-State		Multi-State	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208001800308001800408001800508001800608001800000000000	9108001800208001800308001800408001800508001800608001800708001800	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.aetnamedicare.com	0	0	2	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.aetnamedicaredocfind.com	https://www.aetnamedicare.com/findpharmacy	https://www.aetnaretireeplans.com
H3288	802	0	2021	04	Aetna Medicare Plan w/Rx (PPO)	Multi-State		Multi-State	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3291	001	0	2021	01	PruittHealth Premier (HMO I-SNP)	Georgia (partial)		Georgia (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.pruitthealthpremier.com	1	1	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.pruitthealthpremier.com	www.pruitthealthpremier.com	www.pruitthealthpremier.com
H3291	002	0	2021	01	PruittHealth Premier D-SNP (HMO D-SNP)	Georgia (partial)		Georgia (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.pruitthealthpremier.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.pruitthealthpremier.com	www.pruitthealthpremier.com	www.pruitthealthpremier.com
H3293	003	0	2021	01	MMM EXTRA (HMO)	Counties: Miami-Dade, Broward, Palm Beach	MMM EXTRA (HMO)	Counties: Miami-Dade, Broward, Palm Beach	1	0	0	PO Box 260430		Miami	FL	33126		myra.plumey@mmm-fl.com	myra.plumey@mmm-fl.com	PO Box 260430		Miami	FL	33126		myra.plumey@mmm-fl.com	myra.plumey@mmm-fl.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mmm-fl.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.mmm-fl.com	www.mmm-fl.com	www.mmm-fl.com
H3293	004	0	2021	01	MMM PLATINUM (HMO D-SNP)	Counties: Miami-Dade, Broward, Palm Beach	MMM PLATINUM (HMO D-SNP)	Counties: Miami-Dade, Broward, Palm Beach	1	0	0	PO Box 260430		Miami	FL	33126		myra.plumey@mmm-fl.com	myra.plumey@mmm-fl.com	PO Box 260430		Miami	FL	33126		myra.plumey@mmm-fl.com	myra.plumey@mmm-fl.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mmm-fl.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmm-fl.com	www.mmm-fl.com	www.mmm-fl.com
H3293	005	0	2021	01	MMM ELITE (HMO)	Counties: Miami-Dade, Broward, Palm Beach	MMM ELITE (HMO)	Counties: Miami-Dade, Broward, Palm Beach	1	0	0	PO Box 260430		Miami	FL	33126		myra.plumey@mmm-fl.com	myra.plumey@mmm-fl.com	PO Box 260430		Miami	FL	33126		myra.plumey@mmm-fl.com	myra.plumey@mmm-fl.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mmm-fl.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.mmm-fl.com	www.mmm-fl.com	www.mmm-fl.com
H3305	007	0	2021	02	MVP Medicare Preferred Gold without Part D (HMO-POS)	Western NY (Rochester/Buffalo)		Western NY (Rochester/Buffalo)	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.joinMVPmedicare.com	0	0	2	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	015	0	2021	02	MVP Medicare Preferred Gold with Part D (HMO-POS)	Western NY (Rochester/Buffalo)		Western NY (Rochester/Buffalo)	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.joinMVPmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	020	0	2021	02	MVP Medicare Preferred Gold without Part D (HMO-POS)	S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT		S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.joinmvpmedicare.com	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	021	0	2021	02	MVP Medicare Preferred Gold with Part D (HMO-POS)	S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT		S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.joinmvpmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	022	0	2021	02	MVP Medicare Secure Plus with Part D (HMO-POS)	S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT		S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.joinmvpmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	030	0	2021	02	MVP Medicare Secure with Part D (HMO-POS)	Western NY (Rochester/Buffalo)		Western NY (Rochester/Buffalo)	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.joinmvpmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	032	0	2021	02	MVP Medicare Secure with Part D (HMO-POS)	S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT		S.Tier NY, CNY, Eastern NY, Hudson Valley NY, VT	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.joinMVPmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	801	0	2021	02	MVP Preferred Gold - Employer Group (HMO-POS)	Employer Group West Region		Employer Group West Region	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mvphealthcare.com	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	803	0	2021	02	MVP Preferred Gold Rx - Employer Group (HMO-POS)	Employer Group West Region		Employer Group West Region	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mvphealthcare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3305	804	0	2021	02	MVP Preferred Gold Rx - Employer Group (HMO-POS)	Eastern NY, Hudson Valley NY, Vermont		Eastern NY, Hudson Valley NY, Vermont	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mvphealthcare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H3307	002	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	New York City Metro Area		New York City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3307	012	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Rockland, Orange, and Westchester Counties		Rockland, Orange, and Westchester Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3307	015	0	2021	01	AARP Medicare Advantage Prime (HMO)	New York City Metro Area		New York City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3307	018	0	2021	01	AARP Medicare Advantage Patriot (HMO)	NYC and Rockland, Orange, and Westchester Counties		NYC and Rockland, Orange, and Westchester Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3307	023	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Rockland, Orange, and Westchester Counties		Rockland, Orange, and Westchester Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3307	025	0	2021	01	AARP Medicare Advantage (HMO)	Dutchess, Putnam, Sullivan and Ulster Counties		Dutchess, Putnam, Sullivan and Ulster Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3307	802	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	New York Metropolitan Area		New York Metropolitan Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3307	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	New York Metropolitan Area		New York Metropolitan Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3307	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in New York		Select counties in New York	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3312	002	0	2021	01	Aetna Medicare Value Plan (HMO)	Metro Area: Bronx, Brooklyn, Staten Island		Metro Area: Bronx, Brooklyn, Staten Island	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	018	0	2021	01	Aetna Medicare Value Plan (HMO)	Westchester and Rockland Counties		Westchester and Rockland Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	048	0	2021	01	Aetna Medicare Value Plan (HMO)	Northern Central Upstate New York		Northern Central Upstate New York	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	062	0	2021	01	Aetna Medicare Value Plan (HMO)	Capital Region and Hudson Valley Area		Capital Region and Hudson Valley Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	064	0	2021	01	Aetna Medicare Value Plan (HMO)	Nassau and Suffolk Counties		Nassau and Suffolk Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	065	0	2021	01	Aetna Medicare Value Plan (HMO)	Western New York		Western New York	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	068	0	2021	01	Aetna Medicare Elite Plan (HMO)	Metro Area: NYC and Queens		Metro Area: NYC and Queens	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	069	0	2021	01	Aetna Medicare Assure Plan (HMO D-SNP)	Metro Area: LI, 5 Boroughs, Westchester/Rockland		Metro Area: LI, 5 Boroughs, Westchester/Rockland	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	070	0	2021	01	Aetna Medicare Assure Plan (HMO D-SNP)	Upstate NY Area: HV, Capital, CNY, Rochester, WNY		Upstate NY Area: HV, Capital, CNY, Rochester, WNY	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	801	0	2021	01	Aetna Medicare Plan (HMO)	New York		New York	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3312	804	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	New York		New York	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3321	001	0	2021	20	PACE CNY (PACE)	Onondaga County		Onondaga County	1	3	0									100 Malta Lane		North Syracuse	NY	13212		gturley@lorettosystem.org	gturley@lorettosystem.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacecny.org	0	0	1			0					3	0	0		www.loretto-cny.org	IndependentLivingServicesofCentralNewYork,Inc
H3321	003	0	2021	20	PACE CNY (PACE)	Onondaga County		Onondaga County	1	3	0									100 Malta Lane		North Syracuse	NY	13212		gturley@lorettosystem.org	gturley@lorettosystem.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacecny.org	0	0	1			0					3	0	0		www.loretto-cny.org	IndependentLivingServicesofCentralNewYork,Inc
H3322	001	0	2021	20	Senior Care Connection dba Eddy SeniorCare (PACE)	Schenectady, Albany, Counties, NY		Schenectady, Albany, Counties, NY	1	3	0									1930 Curry Road		Schenectady	NY	12303		Michelle.Mazzacco@sphp.com	Michelle.Mazzacco@sphp.com	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	eddyseniorcare.com	0	0	1			0					3	0	0		www.eddyseniorcare.com	www.eddyseniorcare.com
H3322	002	0	2021	20	Senior Care Connection dba:  Eddy SeniorCare (PACE)	Albany, Rensselaer Counties, NY		Albany, Rensselaer Counties, NY	1	3	0									1930 Curry Road		Schenectady	NY	12303		Michelle.Mazzacco@sphp.com	Michelle.Mazzacco@sphp.com	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	eddyseniorcare.com	0	0	1			0					3	0	0		www.eddyseniorcare.com	www.eddyseniorcare.com
H3329	001	0	2021	20	CenterLight Healthcare PACE Dual Eligible (PACE)	NYC  and Westchester Counties		NYC  and Westchester Counties	1	3	0									1733 Eastchester Road	2nd Floor	Bronx	NY	10461				2108001800208001800308001800408001800508001800608001800708001800	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.centerlighthealthcare.org/	0	0	1			0					3	0	0		N/A	N/A
H3329	002	0	2021	20	CenterLight Healthcare - PACE - Medicare only (PACE)	NYC and Westchester Counties		NYC and Westchester Counties	1	3	0									1733 Eastchester Road	2nd Floor	Bronx	NY	10461				2108001800208001800308001800408001800508001800608001800708001800	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.centerlighthealthcare.org/	0	0	1			0					3	0	0		N/A	N/A
H3330	021	1	2021	01	EmblemHealth VIP Gold (HMO)	NYC, Long Island and Lower Hudson Valley		Bronx, Kings, New York, Queens Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	021	2	2021	01	EmblemHealth VIP Gold (HMO)	NYC, Long Island and Lower Hudson Valley		Nassau and Richmond Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	021	3	2021	01	EmblemHealth VIP Gold (HMO)	NYC, Long Island and Lower Hudson Valley		Suffolk County	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	021	4	2021	01	EmblemHealth VIP Gold (HMO)	NYC, Long Island and Lower Hudson Valley		Lower Hudson Valley Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	032	1	2021	01	EmblemHealth VIP Essential (HMO)	NYC, Long Island and Lower Hudson Valley		Bronx, Kings, New York and Queens Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	032	2	2021	01	EmblemHealth VIP Essential (HMO)	NYC, Long Island and Lower Hudson Valley		Nassau and Richmond Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	032	3	2021	01	EmblemHealth VIP Essential (HMO)	NYC, Long Island and Lower Hudson Valley		Suffolk County	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	032	4	2021	01	EmblemHealth VIP Essential (HMO)	NYC, Long Island and Lower Hudson Valley		Lower Hudson Valley Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	036	0	2021	01	EmblemHealth VIP Value (HMO)	NYC, Long Island, Lower Hudson Valley Counties		NYC, Long Island, Lower Hudson Valley Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	038	0	2021	01	EmblemHealth VIP Gold Plus (HMO)	NYC, Long Island, Lower Hudson Valley Counties		NYC, Long Island, Lower Hudson Valley Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	039	1	2021	01	EmblemHealth VIP Rx Saver (HMO)	Hudson Valley		Lower Hudson Valley Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	039	2	2021	01	EmblemHealth VIP Rx Saver (HMO)	Hudson Valley		Capital Region Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	040	0	2021	01	EmblemHealth VIP Part B Saver (HMO)	NYC, Hudson Valley, Long Island & Capital Region		NYC, Hudson Valley, Long Island & Capital Region	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	041	1	2021	02	EmblemHealth VIP Go (HMO-POS)	NYC, Hudson Valley, Long Island & Capital Region		New York City, Nassau, Hudson Valley Counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	041	2	2021	02	EmblemHealth VIP Go (HMO-POS)	NYC, Hudson Valley, Long Island & Capital Region		Suffolk County	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	042	1	2021	01	EmblemHealth VIP Dual (HMO D-SNP)	NYC, Long Island, Hudson Valley, Capital Distrct		Bronx, Kings, New York and Queens	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	042	2	2021	01	EmblemHealth VIP Dual (HMO D-SNP)	NYC, Long Island, Hudson Valley, Capital Distrct		Suffolk	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	042	3	2021	01	EmblemHealth VIP Dual (HMO D-SNP)	NYC, Long Island, Hudson Valley, Capital Distrct		Hudson Valley and Capital District	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	814	0	2021	01	EmblemHealth VIP Premier (HMO)	New York		New York	1	3	1	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	815	0	2021	01	EmblemHealth VIP Rx Carveout (HMO)	New York		New York	1	3	1	PO Box 4001		Farmington	CT	06034												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	820	0	2021	02	EmblemHealth VIP Choice (HMO-POS)	New York		New York	1	3	1	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3330	821	0	2021	02	EmblemHealth VIP Choice Rx Carveout (HMO-POS)	New York		New York	1	3	1	PO Box 4001		Farmington	CT	06034												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	emblemhealth.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H3331	001	0	2021	20	ElderONE an Affiliate of Rochester Regional Health (PACE)	Monroe, Wayne, Ontario Counties		Monroe, Wayne, Ontario Counties	1	3	0									2066 Hudson Avenue.		Rochester	NY	14617		Jennifer.Affronti@rochesterregional.org	Jennifer.Affronti@rochesterregional.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ElderONE.org	0	0	1			0					3	0	0		www.rochestergeneral.org/hillhaven	www.rochestergeneral.org
H3331	002	0	2021	20	ElderONE an Affiliate of Rochester Regional Health (PACE)	Monroe, Wayne, Ontario Counties		Monroe, Wayne, Ontario Counties	1	3	0									2066 Hudson Avenue.		Rochester	NY	14617		Jennifer.Affronti@rochesterregional.org	Jennifer.Affronti@rochesterregional.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ElderONE.org	0	0	1			0					3	0	0		www.rochestergeneral.org/hillhaven	www.rochestergeneral.org
H3335	014	0	2021	04	Medicare BlueSecure (PPO)	Central New York		Central New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	015	0	2021	04	Medicare BlueEnhanced (PPO)	Central New York		Central New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	018	0	2021	04	Medicare BluePlus (PPO)	East New York		East New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	038	0	2021	04	Medicare BlueClassic (PPO)	Central New York		Central New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	043	0	2021	04	Medicare BlueBasic (PPO)	Central New York		Central New York	1	0	0	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	2	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	044	0	2021	04	Medicare BlueBasic (PPO)	East New York		East New York	1	0	0	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	2	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	053	0	2021	04	Medicare BlueEssential (PPO)	Central New York		Central New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	801	0	2021	04	Univera Medicare PPO Group (PPO)	Western New York		Western New York	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3335	811	0	2021	04	Medicare Blue PPO Group (PPO)	National and Puerto Rico		National and Puerto Rico	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	813	0	2021	04	Univera Medicare PPO Group (PPO)	Western New York		Western New York	1	3	1	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UniveraMedicare.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3335	819	0	2021	04	Medicare Blue PPO Group (PPO)	National and Puerto Rico		National and Puerto Rico	1	3	1	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	820	0	2021	04	Medicare Blue PPO Group Non-Calendar (PPO)	National and Puerto Rico		National and Puerto Rico	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3335	822	0	2021	04	Univera Medicare PPO Group Non-Calendar (PPO)	Western New York		Western New York	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3342	023	1	2021	04	Empire MediBlue Access (PPO)	Select Counties in NY		Columbia, Delaware and Greene Counties	1	0	0	3 Huntington Quadrangle		Melville	NY	11747		mediblue@empireblue.com	mediblue@empireblue.com	3 Huntington Quadrangle		Melville	NY	11747		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.empireblue.com/medicare	https://shop.empireblue.com/medicare	https://shop.empireblue.com/medicare
H3342	023	2	2021	04	Empire MediBlue Access (PPO)	Select Counties in NY		Select Counties in New York	1	0	0	3 Huntington Quadrangle		Melville	NY	11747		mediblue@empireblue.com	mediblue@empireblue.com	3 Huntington Quadrangle		Melville	NY	11747		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.empireblue.com/medicare	https://shop.empireblue.com/medicare	https://shop.empireblue.com/medicare
H3342	808	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	809	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	810	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	812	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	813	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	814	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	815	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	816	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	817	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	818	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	819	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3342	820	0	2021	04	Empire MediBlue Freedom (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/medicare	www.empireblue.com/medicare	www.empireblue.com/medicare
H3344	005	0	2021	04	Independent Health's Medicare Passport Advantage (PPO)	Western New York		Western New York	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3344	010	0	2021	04	Independent Health's Medicare Passport Prime (PPO)	Western New York		Western New York	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3344	801	0	2021	04	Independent Health's Medicare PPO Base (PPO)	IH Network and Medicare Deemed Network		IH Network and Medicare Deemed Network	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3344	804	0	2021	04	Independent Health's Medicare PPO Base (PPO)	IH Network and Medicare Deemed Network		IH Network and Medicare Deemed Network	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3344	805	0	2021	04	Independent Health's Medicare PPO Base (PPO)	National Service Area		National Service Area	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.independentheaalth.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independentheaalth.com/medicare
H3347	002	0	2021	01	Elderplan For Medicaid Beneficiaries (HMO D-SNP)	Brx Ki Na NY Qu Wes		Brx Ki Na NY Qu Wes	1	0	0	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.elderplan.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.elderplan.org	www.caremark.com	www.elderplan.org
H3347	003	0	2021	01	Elderplan Advantage For Nursing Home Residents (HMO I-SNP)	Brx Dut Ki Mon Na NY Ora Put Qu Ri Roc Suf Wes		Brx Dut Ki Mon Na NY Ora Put Qu Ri Roc Suf Wes	1	0	0	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.elderplan.org	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.elderplan.org	www.caremark.com	www.elderplan.org
H3347	007	0	2021	01	Elderplan Plus Long Term Care (HMO D-SNP)	Brx Dut Ki Na NY Ora Put Qu Ri Roc Wes		Brx Dut Ki Na NY Ora Put Qu Ri Roc Wes	1	0	0	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.elderplan.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.elderplan.org	www.caremark.com	www.elderplan.org
H3347	009	0	2021	01	Elderplan Extra Help (HMO)	Brx Ki NY Qu Wes		Brx Ki NY Qu Wes	1	0	0	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.elderplan.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.elderplan.org	www.caremark.com	www.elderplan.org
H3347	015	0	2021	01	Elderplan Assist (HMO I-SNP)	Brx Dut Ki Mon Na NY Ora Put Qu Ri Roc Suf Wes		Brx Dut Ki Mon Na NY Ora Put Qu Ri Roc Suf Wes	1	0	0	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	Elderplan, Inc.	6323 7th Avenue	Brooklyn	NY	11220		SAKHAN@mjhs.org	MemberServices@mjhs.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.elderplan.org	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.elderplan.org	www.caremark.com	www.elderplan.org
H3351	001	0	2021	02	Univera SeniorChoice Select (HMO-POS)	Western New York		Western New York	1	0	0	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	002	0	2021	02	Univera SeniorChoice Secure (HMO-POS)	Western New York		Western New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	006	0	2021	02	Medicare Blue Choice Optimum (HMO-POS)	Metro Rochester Area		Metro Rochester Area	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	007	0	2021	02	Medicare Blue Choice Platinum (HMO-POS)	Metro Rochester Area		Metro Rochester Area	1	0	0	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	010	0	2021	01	Univera SeniorChoice Value (HMO)	Western New York		Western New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	011	0	2021	01	Medicare Blue Choice Value (HMO)	Metro Rochester Area		Metro Rochester Area	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	012	0	2021	02	Univera SeniorChoice Value Plus (HMO-POS)	Western New York		Western New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	013	0	2021	02	Medicare Blue Choice Value Plus (HMO-POS)	Metro Rochester Area		Metro Rochester Area	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	015	0	2021	02	Medicare Bassett (HMO-POS)	East New York		East New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	016	0	2021	01	Medicare Blue Choice Select (HMO)	Metro Rochester Area		Metro Rochester Area	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	017	0	2021	01	Univera SeniorChoice Basic (HMO)	Western New York		Western New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	018	0	2021	02	Medicare Blue Choice Advanced (HMO-POS)	Metro Rochester Area		Metro Rochester Area	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	019	0	2021	02	Univera SeniorChoice Advanced (HMO-POS)	Western New York		Western New York	1	0	0	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	801	0	2021	02	Univera SeniorChoice - Group (HMO-POS)	Western New York		Western New York	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	802	0	2021	02	Medicare Blue Choice - Group (HMO-POS)	Metro Rochester Area and Central New York		Metro Rochester Area and Central New York	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	803	0	2021	02	Univera SeniorChoice - Group (HMO-POS)	Western New York		Western New York	1	3	1	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	804	0	2021	02	Medicare Blue Choice - Group (HMO-POS)	Metro Rochester Area and Central New York		Metro Rochester Area and Central New York	1	3	1	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3351	805	0	2021	02	Univera SeniorChoice Group Non-Calendar (HMO-POS)	Western New York		Western New York	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.UniveraMedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UniveraMedicare.com	www.UniveraMedicare.com	www.UniveraMedicare.com
H3351	806	0	2021	02	Medicare Blue Choice Group Non-Calendar (HMO-POS)	Metro Rochester Area and Central New York		Metro Rochester Area and Central New York	1	3	1	P.O. Box 211316		Eagan	MN	55121				P.O. Box 211316		Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.ExcellusMedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.ExcellusMedicare.com	www.ExcellusMedicare.com	www.ExcellusMedicare.com
H3359	001	0	2021	01	Healthfirst 65 Plus Plan (HMO)	New York City and Nassau County	Plan 65 Plus de Healthfirst (HMO)	New York City and Nassau County	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3359	019	0	2021	01	Healthfirst Increased Benefits Plan (HMO)	NYC, Nassau, Some Lower Hudson Valley Counties	Plan de Beneficios Adicionales de Healthfirst (HMO)	NYC, Nassau, Some Lower Hudson Valley Counties	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3359	021	0	2021	01	Healthfirst Life Improvement Plan (HMO D-SNP)	NYC, Nassau, Some Lower Hudson Valley Counties	Plan Mejor Calidad de Vida de Healthfirst (HMO D-SNP)	NYC, Nassau, Some Lower Hudson Valley Counties	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3359	027	0	2021	01	Healthfirst Coordinated Benefits Plan (HMO)	New York City and Nassau County	Plan de Beneficios Coordinados de Healthfirst (HMO)	New York City and Nassau County	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3359	034	0	2021	01	Healthfirst CompleteCare (HMO D-SNP)	NYC, Nassau, Some Lower Hudson Valley Counties	Atención Integral de Healthfirst (HMO D-SNP)	NYC, Nassau, Some Lower Hudson Valley Counties	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3359	808	0	2021	01	Healthfirst Employer Group 1 (HMO)	United States		United States	1	3	1	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3359	809	0	2021	01	Healthfirst Employer Group 2 (HMO)	United States		United States	1	3	1	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H3362	016	0	2021	01	Independent Health's Encompass 65 (HMO)	Western New York		Western New York	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	017	0	2021	01	Independent Health's Encompass 65 Basic (HMO)	Western New York		Western New York	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	020	0	2021	01	Independent Health's Medicare Family Choice (HMO I-SNP)	Western New York		Western New York	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	033	0	2021	01	Independent Health's Encompass 65 Core (HMO)	Western New York		Western New York	1	0	0	511 Farber Lakes Dr.		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Dr.		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	035	0	2021	01	Independent Health's Assure Advantage (HMO C-SNP)	Erie County		Erie County	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com	1	4	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	038	0	2021	01	Independent Health's Encompass 65 Element (HMO)	Western New York		Western New York	1	0	0	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $375.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $375.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com/medicare
H3362	801	0	2021	01	Independent Health's Medicare Encompass (HMO)	New York State		New York State	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	807	0	2021	02	Independent Health's Medicare Encompass (HMO-POS)	IH Network and Medicare Deemed Network		IH Network and Medicare Deemed Network	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	independenthealth.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	819	0	2021	02	Independent Health's Medicare Encompass (HMO-POS)	IH Network and Medicare Deemed Network		IH Network and Medicare Deemed Network	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	independenthealth.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3362	820	0	2021	01	Independent Health's Medicare Encompass (HMO)	New York State		New York State	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		medicarehelp@independenthealth.com	medicareservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.independenthealth.com	www.independenthealth.com	www.independenthealth.com
H3379	001	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	New York City Metro Area		New York City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3379	002	0	2021	01	UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)	New York City		New York City	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3379	022	0	2021	02	UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)	Upstate New York		Upstate New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3379	039	0	2021	01	AARP Medicare Advantage (HMO)	Syracuse Metro Area		Syracuse Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3379	040	0	2021	01	AARP Medicare Advantage (HMO)	Buffalo Metro Area		Buffalo Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3379	041	0	2021	01	AARP Medicare Advantage (HMO)	Monroe and Wayne Counties		Monroe and Wayne Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3379	042	0	2021	01	UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)	Jefferson County		Jefferson County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3384	013	0	2021	01	BlueShield Senior Blue 652 (HMO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H3384	019	0	2021	01	BlueCross BlueShield Senior Blue 651 (HMO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H3384	022	0	2021	01	BlueCross BlueShield Senior Blue 601 (HMO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H3384	058	0	2021	01	BlueCross BlueShield Senior Blue Select (HMO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H3384	059	0	2021	01	BlueShield Freedom Plus (HMO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H3384	062	0	2021	01	BlueCross BlueShield BlueSaver (HMO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H3384	063	0	2021	01	BlueShield Freedom Value (HMO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H3384	064	0	2021	01	BlueShield Freedom Premier (HMO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H3384	066	0	2021	01	BlueShield Freedom No Rx (HMO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterNENY@bsneny.com	customerservice@bsneny.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H3384	805	0	2021	01	HMO Group MA Only Plan (HMO)	Western and Northeastern New York		Western and Northeastern New York	1	3	1	PO Box 80		Buffalo	NY	14202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nymedicare.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.nymedicare.com	www.bcbswny.com	http://www.bcbswny.com/pharmacy
H3384	806	0	2021	01	HMO Group (MA-PD) Calendar Year (HMO)	Western and Northeastern New York		Western and Northeastern New York	1	3	1	PO Box 80		Buffalo	NY	14202				PO Box 80		Buffalo	NY	14202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nymedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.nymedicare.com	www.bcbswny.com	http://www.bcbswny.com/pharmacy
H3384	811	0	2021	02	HMOPOS Group (MA-PD) Calendar Year (HMO-POS)	Western and Northeastern New York		Western and Northeastern New York	1	3	1	PO Box 80		Buffalo	NY	14202				PO Box 80		Buffalo	NY	14202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.nymedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.nymedicare.com	www.bcbswny.com	http://www.bcbswny.com/pharmacy
H3384	812	0	2021	02	HMOPOS Group MA Only Calendar Year (HMO-POS)	Western and Northeastern New York		Western and Northeastern New York	1	3	1	PO Box 80		Buffalo	NY	14202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.nymedicare.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.nymedicare.com	www.bcbswny.com	http://www.bcbswny.com/pharmacy
H3387	010	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3387	013	0	2021	01	UnitedHealthcare Dual Complete One (HMO D-SNP)	State of New York		State of New York	3	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>Available to current members only.</li><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Solamente disponible a socios activos.</li><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3388	001	0	2021	01	CDPHP Choice (HMO)	Greater Capital Region of New York State	CDPHP Choice (HMO)	Greater Capital Region of New York State	1	0	0	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	002	0	2021	01	CDPHP Choice Rx (HMO)	Greater Capital Region of New York State	CDPHP Choice Rx (HMO)	Greater Capital Region of New York State	1	0	0	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	004	0	2021	01	CDPHP Value Rx (HMO)	Greater Capital Region of New York State	CDPHP Value Rx (HMO)	Greater Capital Region of New York State	1	0	0	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	013	0	2021	01	CDPHP Basic RX (HMO)	Greater Capital Region of New York State	CDPHP Basic RX (HMO)	Greater Capital Region of New York State	1	0	0	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	014	0	2021	01	CDPHP $0 Medicare Rx (HMO)	Greater Capital Region of New York State	CDPHP $0 Medicare Rx (HMO)	Greater Capital Region of New York State	1	0	0	500 Patroon Creek Blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	801	0	2021	01	CDPHP Group Medicare Rx (HMO)	Greater Capital Region of New York State	CDPHP group Medicare Rx (HMO)	Greater Capital Region of New York State	1	3	1	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	803	0	2021	01	CDPHP Group Medicare Rx (HMO)	Greater Capital Region of New York State	CDPHP Group Medicare Rx (HMO)	Greater Capital Region of New York State	1	3	1	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3388	804	0	2021	01	CDPHP Group Medicare (HMO)	Greater Capital Region of New York State	CDPHP Group Medicare (HMO)	Greater Capital Region of New York State	1	3	1	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H3404	003	1	2021	04	Blue Medicare PPO Enhanced (PPO)	Select North Carolina Counties		PPO Region 1	1	0	0	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3404	003	2	2021	04	Blue Medicare PPO Enhanced (PPO)	Select North Carolina Counties		PPO Region 2	1	0	0	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3404	801	0	2021	04	Blue Medicare PPO EGWP Medical Only (PPO)	North Carolina Employer Groups		North Carolina Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/MyRx/MyPrime/MedicareD/pharmacy/BCBSNC	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3404	803	0	2021	04	Blue Medicare PPO EGWP (PPO)	North Carolina Employer Groups		North Carolina Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3404	809	0	2021	04	Blue Medicare PPO EGWP Value (PPO)	NC Employer Groups		NC Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3404	810	0	2021	04	Blue Medicare PPO EGWP Complete (PPO)	NC Employer Groups		NC Employer Groups	1	3	1	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3407	001	0	2021	01	El Paso Health Advantage Dual SNP (HMO D-SNP)	El Paso and Hudspeth counties		El Paso and Hudspeth counties	1	0	0	P. O. Box 971100		El Paso	TX	79997		medicare@elpasohealth.com	medicare@elpasohealth.com	P. O. Box 971100		El Paso	TX	79997		medicare@elpasohealth.com	medicare@elpasohealth.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.ephmedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	ephmedicare.com	ephmedicare.com	ephmedicare.com
H3416	001	6	2021	04	HealthPartners UnityPoint Health Align (PPO)	Central Iowa & Western Illinois		Cedar Rapids, Central IA, and Peoria Areas	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	Oneplanforme.com/medicareplan	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	Oneplanforme.com/findadoctor	Oneplanforme.com/findapharmacy	Oneplanforme.com/myresources
H3416	001	7	2021	04	HealthPartners UnityPoint Health Align (PPO)	Central Iowa & Western Illinois		Fort Dodge, Quad Cities, Waterloo, Sioux City	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	Oneplanforme.com/medicareplan	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	Oneplanforme.com/findadoctor	Oneplanforme.com/findapharmacy	Oneplanforme.com/myresources
H3416	002	4	2021	04	HealthPartners UnityPoint Health Symmetry (PPO)	Central Iowa & Western Illinois		Cedar Rapids, Central IA, and Peoria Areas	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	Oneplanforme.com/medicareplan	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	Oneplanforme.com/findadoctor	Oneplanforme.com/findapharmacy	Oneplanforme.com/myresources
H3416	002	5	2021	04	HealthPartners UnityPoint Health Symmetry (PPO)	Central Iowa & Western Illinois		Fort Dodge, Quad Cities, Waterloo, and Sioux City	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	Oneplanforme.com/medicareplan	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	Oneplanforme.com/findadoctor	Oneplanforme.com/findapharmacy	Oneplanforme.com/myresources
H3416	801	0	2021	04	HealthPartners UnityPoint Health Group MAPD CY (PPO)	Nationwide		Nationwide	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Oneplanforme.com/medicareplan	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	Oneplanforme.com/findadoctor	Oneplanforme.com/findapharmacy	Oneplanforme.com/myresources
H3416	803	0	2021	04	HealthPartners UnityPoint Health Group MA Only (PPO)	Nationwide		Nationwide	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Oneplanforme.com/medicareplan	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	Oneplanforme.com/findadoctor	Oneplanforme.com/findapharmacy	healthpartnersunitypointhealth.com
H3418	001	0	2021	04	AARP Medicare Advantage Mosaic Choice (PPO)	New York City Metro Area		New York City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3419	001	0	2021	01	Perennial Advantage Strive (HMO I-SNP)	Colorado (partial)		Colorado (partial)	1	0	0	9570 S. Kingston Ct.	Suite 300	Englewood	CO	80112				9570 S. Kingston Ct.	Suite 300	Englewood	CO	80112				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.perennialadvantage.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.perennialadvantage.com	www.placeholder.com	www.perennialadvantage.com
H3419	002	0	2021	01	Perennial Advantage Concierge (HMO C-SNP)	Colorado (partial)		Colorado (partial)	1	0	0	9570 S. Kingston Ct.	Suite 300	Englewood	CO	80112				9570 S. Kingston Ct.	Suite 300	Englewood	CO	80112				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.perennialadvantage.com	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.perennialadvantage.com	www.placeholder.com	www.perennialadvantage.com
H3430	001	0	2021	20	Suncoast PACE, Inc. (PACE)	Suncoast PACE, Inc., Pinellas County		Suncoast PACE, Inc., Pinellas County	1	3	0									5771 Roosevelt Blvd		Clearwater	FL	33760		jasonpettry@empathhealth.org	jasonpettry@empathhealth.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.suncoastpace.org	0	0	1			0					3	0	0		http://www.suncoastpace.org/	http://www.suncoastpace.org/
H3430	002	0	2021	20	Suncoast PACE, Inc. (PACE)	Suncoast PACE, Inc., Pinellas County		Suncoast PACE, Inc., Pinellas County	1	3	0									5771 Roosevelt Blvd		Clearwater	FL	33760		jasonpettry@empathhealth.org	jasonpettry@empathhealth.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.suncoastpace.org	0	0	1			0					3	0	0		http://www.suncoastpace.org/	http://www.suncoastpace.org/
H3442	001	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3442	003	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Boston Metro		Boston Metro	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3442	004	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Outside of Boston Metro		Outside of Boston Metro	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3442	005	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Boston and Outside Boston Metro		Boston and Outside Boston Metro	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3442	006	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	State of Rhode Island		State of Rhode Island	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3442	007	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Select counties in New Hampshire		Select counties in New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3442	008	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select counties in New Hampshire		Select counties in New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3447	001	0	2021	01	Anthem MediBlue Local (HMO)	Richmond Metropolitan, West & So. of Richmond Area		Richmond Metropolitan, West & So. of Richmond Area	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	003	0	2021	01	Anthem MediBlue COPD (HMO C-SNP)	Richmond Metropolitan, West & So. of Richmond Area		Richmond Metropolitan, West & So. of Richmond Area	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	004	0	2021	01	Anthem MediBlue Diabetes (HMO C-SNP)	Richmond Metropolitan, West & So. of Richmond Area		Richmond Metropolitan, West & So. of Richmond Area	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	005	0	2021	01	Anthem MediBlue Smart Fit (HMO)	Richmond Metropolitan, West & So. of Richmond Area		Richmond Metropolitan, West & So. of Richmond Area	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	010	0	2021	01	Anthem MediBlue Care On Site (HMO I-SNP)	Richmond Metropolitan, West & So. of Richmond Area		Richmond Metropolitan, West & So. of Richmond Area	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	011	0	2021	01	Anthem MediBlue Full Dual Advantage (HMO D-SNP)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	012	0	2021	01	Anthem MediBlue Full Dual Advantage (HMO D-SNP)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	013	0	2021	01	Anthem MediBlue Plus (HMO)	Southern Virginia Counties		Southern Virginia Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	014	0	2021	01	Anthem MediBlue Plus (HMO)	Northern Virginia Counties		Northern Virginia Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	018	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	019	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	020	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Indiana		Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	021	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	022	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $120.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $120.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	023	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Indiana		Select Counties in Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	024	0	2021	01	Anthem MediBlue Extra (HMO)	Indiana		Indiana	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	025	0	2021	01	Anthem MediBlue Essential (HMO)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H3447	026	0	2021	01	Anthem MediBlue Care To You (HMO I-SNP)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	027	0	2021	01	Anthem MediBlue Extra (HMO)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H3447	028	0	2021	01	Anthem MediBlue Extra (HMO)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	GA	78265				P.O. Box 659404		San Antonio	TX	78265				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H3447	030	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	031	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3447	802	0	2021	01	Anthem MediBlue EGWP MAPD (HMO)	Virginia		Virginia	1	3	1	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	804	0	2021	01	Anthem MediBlue (HMO)	Select counties in Virginia		Select counties in Virginia	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	805	0	2021	01	Anthem MediBlue (HMO)	Select counties in Virginia		Select counties in Virginia	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	806	0	2021	01	Anthem MediBlue (HMO)	Virginia - Select Counties		Virginia - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	807	0	2021	01	Anthem MediBlue (HMO)	Select Virginia Counties		Select Virginia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	808	0	2021	01	Anthem MediBlue (HMO)	Select Virginia Counties		Select Virginia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	809	0	2021	01	Anthem MediBlue (HMO)	Select Virginia Counties		Select Virginia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	810	0	2021	01	Anthem MediBlue (HMO)	Select Virginia Counties		Select Virginia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	811	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	812	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	813	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	814	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	815	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	816	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	817	0	2021	01	Anthem MediBlue (HMO)	Select Indiana Counties		Select Indiana Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	818	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	819	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	820	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	821	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	822	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	823	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	824	0	2021	01	Anthem MediBlue (HMO)	Select Missouri Counties		Select Missouri Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3447	825	0	2021	01	Anthem MediBlue (HMO)	Select Virginia Counties		Select Virginia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/va/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/va/medicare	www.anthem.com/va/medicare	www.anthem.com/va/medicare
H3447	826	0	2021	01	Anthem MediBlue (HMO)	Anthem MediBlue		Anthem MediBlue	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/IN/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare	www.anthem.com/IN/medicare
H3447	827	0	2021	01	Anthem MediBlue (HMO)	Select MO Counties		Select MO Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/MO/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare	www.anthem.com/MO/medicare
H3449	012	0	2021	01	Blue Medicare Medical Only (HMO)	Select North Carolina Counties		Select North Carolina Counties	1	0	0	P.O. Box 17509		Winston Salem	NC	27116												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/MyRx/MyPrime/MedicareD/pharmacy/BCBSNC	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	023	1	2021	01	Blue Medicare Essential Plus (HMO)	Select North Carolina Counties		Essential Plus Region 1	1	0	0	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	023	2	2021	01	Blue Medicare Essential Plus (HMO)	Select North Carolina Counties		Essential Plus Region 2	1	0	0	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	023	4	2021	01	Blue Medicare Essential Plus (HMO)	Select North Carolina Counties		Essential Plus Region 4	1	0	0	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	023	5	2021	01	Blue Medicare Essential Plus (HMO)	Select North Carolina Counties		Essential Plus Region 5	1	0	0	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	024	1	2021	01	Blue Medicare Enhanced (HMO)	Select North Carolina Counties		Enhanced Region 1	1	0	0	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	024	2	2021	01	Blue Medicare Enhanced (HMO)	Select North Carolina Counties		Enhanced Region 2	1	0	0	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	024	3	2021	01	Blue Medicare Enhanced (HMO)	Select North Carolina Counties		Enhanced Region 3	1	0	0	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	025	0	2021	01	Blue Medicare Essential (HMO)	Select North Carolina Counties		Select North Carolina Counties	1	0	0	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $375.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $375.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	026	0	2021	01	Blue Medicare Choice (HMO)	Select North Carolina Counties		Select North Carolina Counties	1	0	0	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	801	0	2021	01	Blue Medicare HMO EGWP (HMO)	North Carolina Employer Groups		North Carolina Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	805	0	2021	01	Blue Medicare HMO EGWP Medical Only (HMO)	North Carolina Employer Groups		North Carolina Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/MyRx/MyPrime/MedicareD/pharmacy/BCBSNC	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	813	0	2021	01	Blue Medicare HMO EGWP Value (HMO)	NC Employer Groups		NC Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116			medsup.info@bcbsnc.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3449	814	0	2021	01	Blue Medicare HMO EGWP Complete (HMO)	NC Employer Groups		NC Employer Groups	1	3	1	P.O. Box 17509		Winston Salem	NC	27116				P.O. Box 17509		Winston Salem	NC	27116				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H3464	001	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Fayetteville Metro Area		Fayetteville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3464	002	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Fayetteville Metro Area		Fayetteville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3464	003	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Little Rock Metro Area		Little Rock Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3464	004	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Little Rock Metro Area		Little Rock Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3464	007	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Entire state of Arkansas		Entire state of Arkansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3467	001	0	2021	01	ProCare Advantage (HMO I-SNP)	Texas (partial)		Texas (partial)	1	0	0	2537 Golden Bear Drive		Carrollton	TX	21122				2537 Golden Bear Drive		Carrollton	TX	21122				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.procareadvantageplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.procareadvantageplan.com	www.procareadvantageplan.com	www.procareadvantageplan.com
H3471	001	0	2021	01	Health Alliance NW Companion Rx (HMO)	Okanogan, Chelan, Douglas, Grant		Okanogan, Chelan, Douglas, Grant	1	0	0	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N. Chelan Ave. Suite A	Suite A	Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	002	0	2021	01	Health Alliance NW Companion Rx Plus (HMO)	Okanogan, Chelan, Douglas, Grant County		Okanogan, Chelan, Douglas, Grant County	1	0	0	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	003	0	2021	01	Health Alliance NW Companion HMO (HMO)	Okanogan, Chelan, Douglas, Grant County		Okanogan, Chelan, Douglas, Grant County	1	0	0	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	004	0	2021	01	Health Alliance NW SignalAdvantage HMO Rx (HMO)	Yakima County		Yakima County	1	0	0	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	005	0	2021	01	Health Alliance NW SignalAdvantage HMO Rx Plus (HMO)	Yakima County		Yakima County	1	0	0	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	006	0	2021	01	Health Alliance NW SignalAdvantage HMO (HMO)	Yakima County		Yakima County	1	0	0	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	010	0	2021	01	Health Alliance NW Companion Basic Rx (HMO)	Okanogan, Chelan, Douglas, Grant County		Okanogan, Chelan, Douglas, Grant County	1	0	0	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	013	0	2021	02	Health Alliance NW SignalAdvantage POS Rx (HMO-POS)	Yakima County		Yakima County	1	0	0	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	014	0	2021	02	Health Alliance NW SignalAdvantage POS Rx Plus (HMO-POS)	Yakima County		Yakima County	1	0	0	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	015	0	2021	02	Health Alliance NW SignalAdvantage POS (HMO-POS)	Yakima County		Yakima County	1	0	0	1701 Creekside Loop #100		Yakima	WA	98902		WAMedicare@healthalliance.org	WAMedicare@healthalliance.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	017	0	2021	01	Health Alliance NW Companion Basic Rx 2 (HMO)	Okanogan, Chelan, Douglas, Grant		Okanogan, Chelan, Douglas, Grant	1	0	0	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		Memberservices@healthalliance.org	Memberservices@healthalliance.org	411 N. Chelan Ave. Suite A		Wenatchee	WA	98802		Memberservices@healthalliance.org	Memberservices@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H3471	018	0	2021	02	Health Alliance NW Companion POS Rx (HMO-POS)	Okanogan, Chelan, Douglas, Grant		Okanogan, Chelan, Douglas, Grant	1	0	0	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N. Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	healthalliancemedicare.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthalliancemedicare.org	healthalliancemedicare.org	healthalliancemedicare.org
H3471	801	0	2021	01	Medicare Employer HMO (HMO)	Central Washington		Central Washington	1	3	1	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	802	0	2021	01	Medicare Employer HMO Rx (HMO)	Central Washington		Central Washington	1	3	1	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	803	0	2021	01	Medicare Employer HMO Rx - non calendar year (HMO)	Central Washington		Central Washington	1	3	1	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N Chelan Ave. Suite A.		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthalliancemedicare.org	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	804	0	2021	02	Medicare Employer HMO-POS (HMO-POS)	Central Washington		Central Washington	1	3	1	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	805	0	2021	02	Medicare Employer HMO-POS with Rx (HMO-POS)	Central Washington		Central Washington	1	3	1	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3471	806	0	2021	02	Medicare Employer HMO-POS with Rx (HMO-POS)	Central Washington		Central Washington	1	3	1	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	411 N Chelan Ave. Suite A		Wenatchee	WA	98801		healthalliancemedicare@healthalliance.org	healthalliancemedicare@healthalliance.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthalliancemedicare.org	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.healthalliancemedicare.org	www.healthalliancemedicare.org	www.healthalliancemedicare.org
H3473	001	0	2021	20	Blue Ridge PACE Dual (PACE)	Blue Ridge PACE Dual		Blue Ridge PACE Dual	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A-noformulary
H3473	002	0	2021	20	Blue Ridge PACE Medicare Only (PACE)	Blue Ridge PACE Medicare Only		Blue Ridge PACE Medicare Only	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A-noformulary
H3493	001	0	2021	20	LIFE at Lourdes, Inc (PACE)	Trinity Health New Jersey, Camden and Burlington		Trinity Health New Jersey, Camden and Burlington	1	3	0									2475 McClellan Ave., Bldg C		Pennsauken	NJ	08109		jruprecht@trinity-health.org	jruprecht@trinity-health.org	2108001700208001700308001700408001700508001700608001700708001700	2108001700208001700308001700408001700508001700608001700708001700	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.trinityhealthLIFE-nj.org	0	0	1			0					3	0	0		www.pharmastarpbm.com	www.trinityhealthpace.org
H3493	002	0	2021	20	LIFE at Lourdes, Inc (PACE)	Trinity Health New Jersey, Camden and Burlington		Trinity Health New Jersey, Camden and Burlington	1	3	0									2475 McClellan Ave., Bldg C		Pennsauken	NJ	08109		jruprecht@trinity-health.org	jruprecht@trinity-health.org	2108001700208001700308001700408001700508001700608001700708001700	2108001700208001700308001700408001700508001700608001700708001700	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.trinityhealthLIFE-nj.org	0	0	1			0					3	0	0		www.pharmastarpbm.com	www.trinityhealthpace.org
H3499	002	0	2021	01	Allwell Medicare (HMO)	Central, Southwest and Northern Indiana		Central, Southwest and Northern Indiana	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3499	005	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	State of Indiana		State of Indiana	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3499	007	0	2021	01	Allwell Medicare Boost (HMO)	State of Indiana		State of Indiana	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3499	008	0	2021	01	Allwell Medicare Complement (HMO)	State of Indiana		State of Indiana	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3499	801	0	2021	01	Allwell Group (HMO)	Indiana		Indiana	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3499	802	0	2021	01	Allwell Group (HMO)	Indiana		Indiana	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3499	803	0	2021	01	Allwell Group (HMO)	Indiana		Indiana	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H3517	001	0	2021	20	Redwood  Coast PACE-Dual (PACE)	Redwood Coast PACE-Dual		Redwood Coast PACE-Dual	1	3	0									1910 California Street		Eureka	CA	95501			PACE@humsenior.org	5000000000208301700308301700408301700508301700608301700000000000	5000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humsenior.org	0	0	1			0					3	0	0	n/a	www.pharmastarpbm.com	www.pharmastarpbm.com
H3517	002	0	2021	20	Redwood Coast PACE-Medicare Only (PACE)	Redwood Coast PACE-Medicare Only		Redwood Coast PACE-Medicare Only	1	3	0									1910 California Street		Eureka	CA	95501			PACE@humsenior.org	5000000000208301700308301700408301700508301700608301700000000000	5000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humsenior.org	0	0	1			0					3	0	0		www.pharmastarpbm.com	www.pharmastarpbm.com
H3522	001	0	2021	20	Reid Health PACE Center (PACE)	Indiana Counties: WY, F, HN, R, U, FR		Indiana Counties: WY, F, HN, R, U, FR	1	3	0									2300 National Road West		Richmond	IN	47374				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.reidhealth.org	0	0	1			0					3	0	0		https://www.carekinesis.com/	N/A
H3522	002	0	2021	20	Reid Health PACE Center (PACE)	Indiana Counties: WY, F, HN, R, U, FR		Indiana Counties: WY, F, HN, R, U, FR	1	3	0									2300 National Road West		Richmond	IN	47374				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.reidhealth.org	0	0	1			0					3	0	0		https://www.carekinesis.com/	N/A
H3528	003	0	2021	01	ConnectiCare Choice Plan 2 (HMO)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034												2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	006	0	2021	02	ConnectiCare Flex Plan 1 (HMO-POS)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	010	0	2021	01	ConnectiCare Passage Plan 1 (HMO)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	011	1	2021	02	ConnectiCare Flex Plan 3 (HMO-POS)	State of Connecticut		Hartford, Litchfield, Middlesex, Tolland counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	011	2	2021	02	ConnectiCare Flex Plan 3 (HMO-POS)	State of Connecticut		Fairfield, New Haven, New London, Windham counties	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	014	0	2021	01	ConnectiCare Choice Plan 3 (HMO)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	015	0	2021	02	ConnectiCare Flex Plan 2 (HMO-POS)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	016	0	2021	01	ConnectiCare Choice Plan 1 (HMO)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	017	0	2021	01	ConnectiCare Choice Part B Saver (HMO)	State of Connecticut		State of Connecticut	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	801	0	2021	01	ConnectiCare Employer Group Plan (HMO)	State of Connecticut		State of Connecticut	1	3	1	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	805	0	2021	01	ConnectiCare Employer Group Plan (HMO)	State of Connecticut		State of Connecticut	1	3	1	PO Box 4001		Farmington	CT	06034												2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.connecticare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	806	0	2021	02	ConnectiCare Employer Group Plan (HMO-POS)	U.S and Territories		U.S and Territories	1	3	1	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.connecticare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3528	807	0	2021	02	ConnectiCare Employer Group Plan (HMO-POS)	U.S and Territories		U.S and Territories	1	3	1	PO Box 4001		Farmington	CT	06034												2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.connecticare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.connecticare.com/medicare	www.connecticare.com/medicare	www.connecticare.com/medicare
H3533	001	0	2021	01	Humana Gold Plus H3533-001 (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	002	0	2021	01	Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	006	0	2021	01	Humana Gold Plus H3533-006 (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	010	0	2021	01	Humana Gold Plus H3533-010 (HMO)	Nassau and Suffolk counties		Nassau and Suffolk counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	013	0	2021	01	Humana Gold Plus H3533-013 (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	027	0	2021	01	Humana Gold Plus H3533-027 (HMO)	New York City and Long Island		New York City and Long Island	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	031	0	2021	01	Humana Gold Plus SNP-DE H3533-031 (HMO D-SNP)	New York City and Long Island		New York City and Long Island	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	032	1	2021	01	Humana Gold Plus H3533-032 (HMO)	New York City		Select Counties in New York City	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	032	2	2021	01	Humana Gold Plus H3533-032 (HMO)	New York City		Richmond County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	033	0	2021	01	Humana Gold Plus H3533-033 (HMO)	Brooklyn and Queens		Brooklyn and Queens	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	802	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in NY		Select Counties in NY	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	803	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in NY		Select Counties in NY	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	805	0	2021	01	Humana Medicare Employer (HMO)	Select counties in NY		Select counties in NY	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3533	806	0	2021	01	Humana Medicare Employer (HMO)	Select counties in NY		Select counties in NY	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H3536	002	0	2021	01	Anthem MediBlue Plus (HMO)	State of  New Hampshire		State of  New Hampshire	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3536	004	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	Select Counties in New Hampshire		Select Counties in New Hampshire	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3536	005	0	2021	01	Anthem MediBlue Select (HMO)	Select Counties in New Hampshire		Select Counties in New Hampshire	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3536	801	0	2021	01	Anthem MediBlue (HMO)	Select counties in New Hampshire		Select counties in New Hampshire	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	802	0	2021	01	Anthem MediBlue (HMO)	Select Counties in New Hampshire		Select Counties in New Hampshire	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	803	0	2021	01	Anthem MediBlue (HMO)	New Hampshire - Select Counties		New Hampshire - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	804	0	2021	01	Anthem MediBlue (HMO)	Select New Hampshire Counties		Select New Hampshire Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	805	0	2021	01	Anthem MediBlue (HMO)	Select New Hampshire Counties		Select New Hampshire Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	806	0	2021	01	Anthem MediBlue (HMO)	Select New Hampshire Counties		Select New Hampshire Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	807	0	2021	01	Anthem MediBlue (HMO)	Select New Hampshire Counties		Select New Hampshire Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3536	808	0	2021	01	Anthem MediBlue (HMO)	Select NH counties		Select NH counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/nh/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare	www.anthem.com/nh/medicare
H3554	001	0	2021	04	BlueMedicare Saver Choice (PPO)	Select Counties in North Central AR		Select Counties in North Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $385.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $385.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	002	0	2021	04	BlueMedicare Saver Choice (PPO)	Select Counties in Northeast, North, and South AR		Select Counties in Northeast, North, and South AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $385.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $385.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	003	0	2021	04	BlueMedicare Value Choice (PPO)	Select Counties in Northwest, West, and Central AR		Select Counties in Northwest, West, and Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	004	0	2021	04	BlueMedicare Value Choice (PPO)	Select Counties in North Central AR		Select Counties in North Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	005	0	2021	04	BlueMedicare Value Choice (PPO)	Select Counties in West, Central, and Northeast AR		Select Counties in West, Central, and Northeast AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	006	0	2021	04	BlueMedicare Value Choice (PPO)	Select Counties in Northeast, North, and South AR		Select Counties in Northeast, North, and South AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	007	0	2021	04	BlueMedicare Premier Choice (PPO)	Select Counties in Northwest, West, and Central AR		Select Counties in Northwest, West, and Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	008	0	2021	04	BlueMedicare Premier Choice (PPO)	Select Counties in North Central AR		Select Counties in North Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	009	0	2021	04	BlueMedicare Premier Choice (PPO)	Select Counties in West, Central, and Northeast AR		Select Counties in West, Central, and Northeast AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3554	010	0	2021	04	BlueMedicare Premier Choice (PPO)	Select Counties in Northeast, North, and South AR		Select Counties in Northeast, North, and South AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H3557	001	0	2021	04	HealthMate for Medicare (PPO)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H3557	801	0	2021	04	HealthMate Coast-to-Coast for Medicare Group (PPO)	RI, Nationwide		RI, Nationwide	1	3	1	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H3561	001	0	2021	01	Health Net Amber II Premier (HMO D-SNP)	Fresno and Sacramento Counties	Health Net Amber II Premier (HMO D-SNP)	Fresno and Sacramento Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	002	0	2021	01	Health Net Sapphire Premier (HMO)	Ala, Fre, Ker, LA, Ora, SD, SF and Tul Counties	Health Net Sapphire Premier (HMO)	Ala, Fre, Ker, LA, Ora, SD, SF and Tul Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	004	0	2021	01	Health Net Sapphire Premier (HMO)	Imperial, Riverside, San Bernardino Counties	Health Net Sapphire Premier (HMO)	Imperial, Riverside, San Bernardino Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	005	0	2021	01	Health Net Sapphire Premier II (HMO)	Ala, Fre, Ker, LA, Ora, SD, SF and Tul Counties	Health Net Sapphire Premier II (HMO)	Ala, Fre, Ker, LA, Ora, SD, SF and Tul Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	006	0	2021	01	Health Net Sapphire Premier II (HMO)	Imperial, Riverside, San Bernardino Counties	Health Net Sapphire Premier II (HMO)	Imperial, Riverside, San Bernardino Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ca.healthnetadvantage.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	801	0	2021	01	Health Net Seniority Plus Employer (HMO)	California		California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthnet.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	802	0	2021	01	Health Net Seniority Plus Employer (HMO)	California		California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthnet.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3561	803	0	2021	01	Health Net Seniority Plus Employer (HMO)	California		California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthnet.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/findadoctor	ca.healthnetadvantage.com/formulary
H3563	001	0	2021	20	Gary and Mary West Senior Services, Inc (PACE)	San Diego North County		San Diego North County	1	3	0									1706 Descanso Avenue		San Marcos	CA	92078				5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	westpace.org	0	0	1			0					3	0	0		www.Carekinesis.com	www.westpace.org
H3563	002	0	2021	20	Gary and Mary West Senior Services, Inc (PACE)	San Diego North County		San Diego North County	1	3	0									1706 Descanso Avenue		San Marcos	CA	92078				5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	westpace.org	0	0	1			0					3	0	0		www.Carekinesis.com	www.westpace.org
H3572	001	0	2021	01	PHP (HMO C-SNP)	Fulton County, Georgia	PHP (HMO C-SNP)	Fulton County, Georgia	1	0	0	P.O. Box 46160		Los Angeles	CA	90046		php@positivehealthcare.org	php@positivehealthcare.org	P.O. Box 46160		Los Angeles	CA	90046		php@positivehealthcare.org	php@positivehealthcare.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.php-ga.org	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.php-ga.org/provider-find	www.php-ga.org/provider-find	www.php-ga.org/for-members/drug-benefit/formulary
H3597	001	0	2021	01	Aetna Medicare Value Plan (HMO)	Southern Maine		Southern Maine	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3597	007	0	2021	01	Aetna Medicare Value Plan (HMO)	Mid Maine		Mid Maine	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3597	009	0	2021	01	Aetna Medicare Value Plan (HMO)	Northern and Additional Maine		Northern and Additional Maine	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3597	011	0	2021	02	Aetna Medicare Assure Plan (HMO-POS D-SNP)	Maine		Maine	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3597	801	0	2021	01	Aetna Medicare Plan (HMO)	Maine		Maine	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3597	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Maine		Maine	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3613	001	0	2021	20	McGregor PACE Dual Eligibles (PACE)	McGregor PACE Cuyahoga County		McGregor PACE Cuyahoga County	1	3	0									26310 Emery Road		Warrensville Heights	OH	44128		Tangi.McCoy@mcgregorctr.org	Tangi.McCoy@mcgregorctr.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.mcgregorpace.org/	0	0	1			0					3	0	0		http://www.catamaranrx.com/	http://www.catamaranrx.com/
H3613	002	0	2021	20	McGregor PACE Medicare Only Eligibles (PACE)	McGregor PACE Cuyahoga County		McGregor PACE Cuyahoga County	1	3	0									26310 Emery Road		Warrensville Heights	OH	44128		Tangi.McCoy@mcgregorctr.org	Tangi.McCoy@mcgregorctr.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.mcgregorpace.org/	0	0	1			0					3	0	0		http://www.catamaranrx.com/	http://www.catamaranrx.com/
H3632	001	0	2021	04	Medica Advantage Solution H3632-001 (PPO)	Select counties in IA and NE		Select counties in IA and NE	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H3653	004	0	2021	01	Paramount Elite - Enhanced Medical & Drug (HMO)	Paramount Elite - Enhanced (Northern OH / SE Mich)		Paramount Elite - Enhanced (Northern OH / SE Mich)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	015	0	2021	01	Paramount Elite - Standard Medical & Drug (HMO)	Paramount Elite - Standard (Northern OH / SE Mich)		Paramount Elite - Standard (Northern OH / SE Mich)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	018	0	2021	01	Paramount Elite - Enhanced Medical Only (HMO)	Paramount Elite - Medical Only (North OH/ SE Mich)		Paramount Elite - Medical Only (North OH/ SE Mich)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	022	0	2021	01	Paramount Elite - Prime Medical & Drug (HMO)	Paramount Elite - Prime (Northern OH / SE Mich)		Paramount Elite - Prime (Northern OH / SE Mich)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	023	0	2021	01	Paramount Elite Choice Medical & Drug (HMO)	Paramount Elite- Choice (Southwestern Ohio)		Paramount Elite- Choice (Southwestern Ohio)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	024	0	2021	01	Paramount Elite Essential Medical & Drug (HMO)	Paramount Elite - Essential (Southwestern Ohio)		Paramount Elite - Essential (Southwestern Ohio)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	803	0	2021	01	Paramount Elite - Emp Group A/B No Rx (HMO)	Paramount Elite - Emp Group A/B No Rx		Paramount Elite - Emp Group A/B No Rx	1	3	1	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	paramounthealthcare.com/medicareplans	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	806	0	2021	01	Paramount Elite - Emp Group B Only No Rx (HMO)	Paramount Elite - Emp Group B Only No Rx		Paramount Elite - Emp Group B Only No Rx	1	3	1	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	paramounthealthcare.com/medicareplans	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3653	809	0	2021	01	Paramount Elite-Emp Group A/B Rx (HMO)	Paramount Elite-Emp Group A/B Rx		Paramount Elite-Emp Group A/B Rx	1	3	1	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H3655	032	0	2021	01	Anthem MediBlue Essential (HMO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $60.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $60.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	033	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	034	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	038	0	2021	01	Anthem MediBlue Prime Select (HMO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	040	0	2021	01	Anthem MediBlue Preferred (HMO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	041	0	2021	01	Anthem MediBlue Extra (HMO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	042	0	2021	01	Anthem MediBlue Preferred Plus (HMO)	Select counties in Ohio		Select counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H3655	801	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	803	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	805	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	806	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	807	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	808	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	809	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3655	810	0	2021	01	Anthem Senior Advantage (HMO)	Ohio		Ohio	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/oh/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare	www.anthem.com/oh/medicare
H3660	028	0	2021	02	SummaCare Medicare Emerald (HMO-POS)	Northeast Ohio		Northeast Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44308		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	029	0	2021	02	SummaCare Medicare Sapphire (HMO-POS)	Northeast Ohio		Northeast Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	044	0	2021	01	SummaCare Medicare Ruby (HMO)	Northeast Ohio		Northeast Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	047	0	2021	01	SummaCare Medicare Ruby (HMO)	Northwest Ohio		Northwest Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44308		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	048	0	2021	02	SummaCare Medicare Sapphire (HMO-POS)	Northwest Ohio		Northwest Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	050	0	2021	01	SummaCare Medicare Topaz (HMO)	Northeast Ohio		Northeast Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	052	1	2021	01	SummaCare Medicare Amber (HMO)	Northeast and Northwest Ohio		Northeast Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	http://medicare.summacare.com/member/drug_benefits/FindaDrug.aspx
H3660	052	2	2021	01	SummaCare Medicare Amber (HMO)	Northeast and Northwest Ohio		Northwest Ohio	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	http://medicare.summacare.com/member/drug_benefits/FindaDrug.aspx
H3660	053	1	2021	01	SummaCare Medicare Garnet (HMO)	Cuyahoga, Geauga, Lake, Lorain, Mahoning, Trumbull		Summit, Stark, Portage, Medina and Wayne Counties	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44308		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	053	2	2021	01	SummaCare Medicare Garnet (HMO)	Cuyahoga, Geauga, Lake, Lorain, Mahoning, Trumbull		Cuyahoga, Geauga, Lake, Lorain, Mahoning, Trumbull	1	0	0	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44308		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	801	0	2021	01	SummaCare Medicare Employer Plan with Part D (HMO)	Nationwide Service Area		Nationwide Service Area	1	3	1	P.O. Box 3620		Akron	OH	44309		Medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	802	0	2021	01	SummaCare Medicare Employer Plan without Part D (HMO)	Nationwide Service Area		Nationwide Service Area	1	3	1	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.summacare.com/medicare	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	http://medicare.summacare.com/member/drug_benefits/FindaDrug.aspx
H3660	805	0	2021	02	SummaCare Medicare Employer Plan with Part D (HMO-POS)	Nationwide Service Area		Nationwide Service Area	1	3	1	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.summacare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	www.summacare.com/medicare
H3660	806	0	2021	02	SummaCare Medicare Employer Plan without Part D (HMO-POS)	Nationwide Service Area		Nationwide Service Area	1	3	1	P.O. Box 3620		Akron	OH	44309		medicareinfo@summacare.com	medicarecustomerservice@summacare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.summacare.com/medicare	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.summacare.com/medicare	www.summacare.com/medicare	http://medicare.summacare.com/member/drug_benefits/FindaDrug.aspx
H3664	014	0	2021	02	PrimeTime Health Plan Basic - MA Only (HMO-POS)	Operating in 12 counties in Northeastern Ohio		Operating in 12 counties in Northeastern Ohio	1	0	0	Morrow House	2600 Sixth Street SW	Canton	OH	44710												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	017	0	2021	02	PrimeTime Health Plan Plus (HMO-POS)	Operating in 12 counties in Northeastern Ohio		Operating in 12 counties in Northeastern Ohio	1	0	0	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	020	0	2021	02	PrimeTime Health Plan Classic (HMO-POS)	Operating in 12 counties in Northeastern Ohio		Operating in 12 counties in Northeastern Ohio	1	0	0	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	021	0	2021	02	PrimeTime Health Plan Aultimate (HMO-POS)	Operating in 12 counties in Northeastern Ohio		Operating in 12 counties in Northeastern Ohio	1	0	0	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	801	0	2021	02	PrimeTime Health Plan Employer Group HMO  - CY (HMO-POS)	National Service Area		National Service Area	1	3	1	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	802	0	2021	02	PrimeTime Health Plan Employer Group HMO MA-Only (HMO-POS)	National Service Area		National Service Area	1	3	1	Morrow House	2600 Sixth Street SW	Canton	OH	44710												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	803	0	2021	02	PrimeTime Health Plan Employer Group - Non CY (HMO-POS)	National Service Area		National Service Area	1	3	1	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	805	0	2021	02	Part B Only MA-PD (HMO-POS)	Part B Only MA-PD National Service Area		Part B Only MA-PD National Service Area	1	3	1	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	806	0	2021	02	Part B Only MA (HMO-POS)	Part B Only MA National Service Area		Part B Only MA National Service Area	1	3	1	Morrow House	2600 Sixth Street SW	Canton	OH	44710												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3664	807	0	2021	02	PrimeTime Health Plan Employer Group HMO - CY (HMO-POS)	National Service Area		National Service Area	1	3	1	Morrow House	2600 Sixth Street SW	Canton	OH	44710				Morrow House	2600 Sixth Street SW	Canton	OH	44710				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.primetimehealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.primetimehealthplan.com	www.primetimehealthplan.com	www.primetimehealthplan.com
H3668	013	0	2021	01	MediGold Medical Only (HMO)	Central, Southeast, Southwest and Northwest OH		Central, Southeast, Southwest and Northwest OH	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	014	0	2021	01	MediGold Southeast OH Classic Preferred (HMO)	Southeast Ohio		Southeast Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	015	0	2021	01	MediGold Southeast OH Essential Care (HMO)	Southeast Ohio		Southeast Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	016	0	2021	01	MediGold Southwest OH Classic Preferred (HMO)	Greater Cincinnati and Champaign County Ohio		Greater Cincinnati and Champaign County Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	017	0	2021	01	MediGold Southwest OH Essential Care (HMO)	Greater Cincinnati and Champaign County Ohio		Greater Cincinnati and Champaign County Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	018	1	2021	01	MediGold Classic Preferred (HMO)	Greater Central Ohio		Greater Columbus Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	018	2	2021	01	MediGold Classic Preferred (HMO)	Greater Central Ohio		Greater Dayton Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	018	3	2021	01	MediGold Classic Preferred (HMO)	Greater Central Ohio		Southern Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	019	1	2021	01	MediGold Essential Care (HMO)	Greater Central Ohio		Greater Columbus Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	019	2	2021	01	MediGold Essential Care (HMO)	Greater Central Ohio		Greater Dayton Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	019	3	2021	01	MediGold Essential Care (HMO)	Greater Central Ohio		Southern Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	020	0	2021	01	MediGold Essential Care (HMO)	Greater Toledo Ohio		Greater Toledo Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	021	0	2021	01	MediGold True Advantage (HMO)	Greater Toledo Ohio		Greater Toledo Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	022	0	2021	01	MediGold True Advantage (HMO)	Greater Columbus Ohio		Greater Columbus Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	023	0	2021	01	MediGold True Advantage (HMO)	Greater Dayton Ohio		Greater Dayton Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	024	0	2021	01	MediGold True Advantage (HMO)	Greater Cincinnati and Champaign County Ohio		Greater Cincinnati and Champaign County Ohio	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	025	0	2021	01	MediGold Essential Care (HMO)	Greater Des Moines Area		Greater Des Moines Area	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	026	0	2021	01	MediGold True Advantage (HMO)	Greater Des Moines Area		Greater Des Moines Area	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	027	0	2021	01	MediGold Essential Care (HMO)	Greater Mason City Area		Greater Mason City Area	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	028	0	2021	01	MediGold True Advantage (HMO)	Greater Mason City Area		Greater Mason City Area	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	029	0	2021	01	MediGold Medical Only (HMO)	Central and Northern Iowa		Central and Northern Iowa	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213												3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	801	0	2021	01	EGWP MediGold Medical Only (HMO)	Central, Southeast and Southwest OH		Central, Southeast and Southwest OH	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	802	0	2021	01	EGWP MediGold Classic (HMO)	Central, Southeast and Southwest OH		Central, Southeast and Southwest OH	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	803	0	2021	01	EGWP MediGold Custom (HMO)	Central, Southeast and Southwest OH		Central, Southeast and Southwest OH	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	804	0	2021	01	EGWP MediGold Classic (HMO)	Central, Southeast and Southwest OH		Central, Southeast and Southwest OH	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	805	0	2021	01	EGWP MediGold Southeast OH Medical Only (HMO)	Southeast Ohio		Southeast Ohio	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	806	0	2021	01	EGWP MediGold Southeast OH Classic (HMO)	Southeast Ohio		Southeast Ohio	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	807	0	2021	01	EGWP MediGold Southeast OH Custom (HMO)	Southeast Ohio		Southeast Ohio	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	808	0	2021	01	EGWP MediGold Southwest OH Medical Only (HMO)	Southwest Ohio		Southwest Ohio	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	809	0	2021	01	EGWP MediGold Southwest OH Classic (HMO)	Southwest Ohio		Southwest Ohio	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3668	810	0	2021	01	EGWP MediGold Southwest OH Custom (HMO)	Southwest Ohio		Southwest Ohio	1	3	1	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H3672	013	0	2021	01	The Health Plan SecureCare - Option II (HMO)	East Central Ohio		East Central Ohio	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	014	0	2021	01	The Health Plan SecureCare - Option I, MA Only (HMO)	East Central Ohio		East Central Ohio	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	019	0	2021	01	The Health Plan SecureCare SNP (HMO D-SNP)	Southeastern Ohio, West Virginia		Southeastern Ohio, West Virginia	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	020	0	2021	01	The Health Plan SecureCare - Option II (HMO)	Southeastern OH, West Virginia		Southeastern OH, West Virginia	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	021	0	2021	01	The Health Plan SecureCare - Option I, MA Only (HMO)	Southeastern OH, West Virginia		Southeastern OH, West Virginia	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	023	0	2021	01	The Health Plan SecureCare Capitol Plan (HMO)	Kanawha and Surrounding Counties		Kanawha and Surrounding Counties	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	024	0	2021	01	The Health Plan SecureCare Capitol Plan, MA Only (HMO)	Kanawha and Surrounding Counties		Kanawha and Surrounding Counties	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org									3000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	025	0	2021	01	WVU Medicine - The Health Plan SecureCare (HMO)	WVU Medicine Service Area		WVU Medicine Service Area	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3672	805	0	2021	01	The Health Plan SecureCare - Employer (HMO)	East Ohio and West Virginia, National		East Ohio and West Virginia, National	1	3	1	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H3706	001	0	2021	01	Generations Classic (HMO)	Oklahoma (Partial)		Oklahoma (Partial)	1	0	0	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	210 Park Ave, Ste 2800		Oklahoma City	OK	73102				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GlobalHealth.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3706	009	0	2021	01	Generations Value (HMO)	Oklahoma (Partial)		Oklahoma (Partial)	1	0	0	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GlobalHealth.com/medicare	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3706	018	0	2021	01	Generations Select (HMO)	Oklahoma (Partial)		Oklahoma (Partial)	1	0	0	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GlobalHealth.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHhealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3706	021	0	2021	02	Generations Classic Choice (HMO-POS)	Oklahoma (Partial)		Oklahoma (Partial)	1	0	0	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	210 Park Ave, Ste 2800		Oklahoma City	OK	73102				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.GlobalHealth.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3706	803	0	2021	01	Generations EGHP CY (HMO)	Oklahoma (Partial)		Oklahoma (Partial)	1	3	1	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GlobalHealth.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3706	804	0	2021	01	Generations EGHP Non CY (HMO)	Oklahoma (Partial)		Oklahoma (Partial)	1	3	1	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GlobalHealth.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3706	807	0	2021	01	Generations EGHP MA only (HMO)	Oklahoma (Partial)		Oklahoma (Partial)	1	3	1	210 Park Ave, Ste 2800		Oklahoma City	OK	73102		MedicareAnswers@globalhealth.com	MedicareAnswers@globalhealth.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GlobalHealth.com/medicare	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.GlobalHealth.com/provider-search	www.GlobalHealth.com/pharmacy-directories	www.GlobalHealth.com/medicare/member-materials
H3708	001	0	2021	01	American Health Advantage of Oklahoma (HMO I-SNP)	Central and East Oklahoma		Central and East Oklahoma	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	ok.AmHealthPlans.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	ok.AmHealthPlans.com	ok.AmHealthPlans.com	ok.AmHealthPlans.com
H3725	001	0	2021	04	Bright Advantage Choice Plus (PPO)	Chicago Area		Chicago Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3725	004	0	2021	04	Bright Advantage Choice (PPO)	Chicago Area		Chicago Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H3727	001	1	2021	01	CommuniCare Advantage CSNP (HMO C-SNP)	Indiana, Maryland and Ohio		Marion County Indiana	1	0	0	CommuniCare Advantage	4700 Ashwood Drive Suite 200	Cincinnati	OH	45241				CommuniCare Advantage	4700 Ashwood Drive Suite 200	Cincinnati	OH	45241				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.communicare-advantage.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.communicare-advantage.com	www.communicare-advantage.com	www.communicare-advantage.com
H3727	001	2	2021	01	CommuniCare Advantage CSNP (HMO C-SNP)	Indiana, Maryland and Ohio		Baltimore City, MD	1	0	0	CommuniCare Advantage	4700 Ashwood Drive Suite 200	Cincinnati	OH	45241				CommuniCare Advantage	4700 Ashwood Drive Suite 200	Cincinnati	OH	45241				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.communicare-advantage.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.communicare-advantage.com	www.communicare-advantage.com	www.communicare-advantage.com
H3727	001	3	2021	01	CommuniCare Advantage CSNP (HMO C-SNP)	Indiana, Maryland and Ohio		Cuyahoga, Franklin and Hamilton Ohio	1	0	0	CommuniCare Advantage	4700 Ashwood Drive Suite 200	Cincinnati	OH	45241				CommuniCare Advantage	4700 Ashwood Drive Suite 200	Cincinnati	OH	45241				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.communicare-advantage.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.communicare-advantage.com	www.communicare-advantage.com	www.communicare-advantage.com
H3727	002	1	2021	01	CommuniCare Advantage ISNP (HMO I-SNP)	Indiana, Maryland and Ohio		Indiana	1	0	0	CommuniCare Advantage	4700 Ashwood Drive, Suite 200	Cincinnati	OH	45241				CommuniCare Advantage	4700 Ashwood Drive, Suite 200	Cincinnati	OH	45241				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.communicare-advantage.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.communicare-advantage.com	www.communicare-advantage.com	www.communicare-advantage.com
H3727	002	2	2021	01	CommuniCare Advantage ISNP (HMO I-SNP)	Indiana, Maryland and Ohio		Maryland	1	0	0	CommuniCare Advantage	4700 Ashwood Drive, Suite 200	Cincinnati	OH	45241				CommuniCare Advantage	4700 Ashwood Drive, Suite 200	Cincinnati	OH	45241				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.communicare-advantage.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.communicare-advantage.com	www.communicare-advantage.com	www.communicare-advantage.com
H3727	002	3	2021	01	CommuniCare Advantage ISNP (HMO I-SNP)	Indiana, Maryland and Ohio		Ohio	1	0	0	CommuniCare Advantage	4700 Ashwood Drive, Suite 200	Cincinnati	OH	45241				CommuniCare Advantage	4700 Ashwood Drive, Suite 200	Cincinnati	OH	45241				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.communicare-advantage.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.communicare-advantage.com	www.communicare-advantage.com	www.communicare-advantage.com
H3748	001	0	2021	01	Aetna Medicare Value Plan (HMO)	Spokane County		Spokane County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	003	0	2021	01	Aetna Medicare Value Plus Plan (HMO)	Puget Sound		Puget Sound	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	004	0	2021	01	Aetna Medicare Platinum Plus Plan (HMO)	Puget Sound		Puget Sound	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	005	0	2021	01	Aetna Medicare Value Plan (HMO)	Southwest Washington		Southwest Washington	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	006	0	2021	01	Aetna Medicare Elite Plan (HMO)	Southwest Washington		Southwest Washington	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	007	0	2021	01	Aetna Medicare Elite Plan (HMO)	Spokane County		Spokane County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	008	0	2021	01	Aetna Medicare Prime Plan (HMO)	Pierce County		Pierce County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	009	0	2021	01	Aetna Medicare Elite Plan (HMO)	Puget Sound		Puget Sound	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	801	0	2021	01	Aetna Medicare Plan (HMO)	Washington		Washington	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3748	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Washington		Washington	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3749	001	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Oklahoma City Metro Area	AARP MedicareComplete (HMO-POS)	Oklahoma City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3749	017	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Tulsa Metro Area		Tulsa Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3749	018	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Oklahoma City Metro Area		Oklahoma City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3749	020	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Tulsa Metro Area		Tulsa Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3749	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	OK Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	OK Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3749	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	OK Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	OK Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3749	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	OK Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	OK Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3755	001	0	2021	01	Senior Health Plan Platinum (HMO)	Counties CG,CK,MC,MU,MY,NO,OG,OS,RB,RG,TU,WG,WS		Counties CG,CK,MC,MU,MY,NO,OG,OS,RB,RG,TU,WG,WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com/2021/SHP	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com/2021/SHP	www.ccokadvantage.com/2021/shp/pharmacy-and-Rx-info.asp	www.medicareplanrx.com/jccf/ccok_shp_formulary_21.html
H3755	002	0	2021	01	Senior Health Plan Silver (HMO)	Counties CG,CK,MC,MY,MU,NO,OG,OS,RB,RG,TU,WG, WS		Counties CG,CK,MC,MY,MU,NO,OG,OS,RB,RG,TU,WG, WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com/2021/SHP	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com/2021/SHP	www.ccokadvantage.com/2021/shp/pharmacy-and-Rx-info.asp	www.medicareplanrx.com/jccf/ccok_shp_formulary_21.html
H3755	004	0	2021	01	Senior Health Plan Platinum Plus (HMO)	Counties CG,CK,MC,MU,MY,NO,OG,OS,RB,RG, TU,WG,WS		Counties CG,CK,MC,MU,MY,NO,OG,OS,RB,RG, TU,WG,WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com/2021/SHP	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com/2021/SHP	www.ccokadvantage.com/2021/SHP/Pharmacy-and-Rx-Info.asp	www.medicareplanrx.com/jccf/ccok_shp_formulary_21.html
H3755	005	0	2021	01	Senior Health Plan Silver Plus (HMO)	Counties CG,CK,MC,MU,MY,NO,OG,OS,RB,RG, TU,WG,WS		Counties CG,CK,MC,MU,MY,NO,OG,OS,RB,RG, TU,WG,WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com/2021/SHP	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com/2021/SHP	www.ccokadvantage.com/2021/SHP/Pharmacy-and-Rx-Info.asp	www.medicareplanrx.com/jccf/ccok_shp_formulary_21.html
H3755	801	0	2021	01	Senior Health EGHP+D (HMO)	Counties CG, CK, MC, MU, NO, OS, TU, WG, WS		Counties CG, CK, MC, MU, NO, OS, TU, WG, WS	1	3	1	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com/2021/SHP	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com/2021/SHP	www.ccokadvantage.com/2021/SHP/Pharmacy-and-Rx-Info.asp	www.medicareplanrx.com/jccf/ccok_shp_formulary_21.html
H3777	001	2	2021	01	Experience Health Medicare Advantage (HMO)	Triangle and surrounding area		Durham Region	1	0	0	PO Box 52382		Durham	NC	27717				PO Box 52382		Durham	NC	27717				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.experiencehealthnc.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.experiencehealthnc.com	www.experiencehealthnc.com
H3777	001	3	2021	01	Experience Health Medicare Advantage (HMO)	Triangle and surrounding area		Orange Region	1	0	0	PO Box 52382		Durham	NC	27717				PO Box 52382		Durham	NC	27717				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.experiencehealthnc.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.experiencehealthnc.com	www.experiencehealthnc.com
H3777	001	4	2021	01	Experience Health Medicare Advantage (HMO)	Triangle and surrounding area		Raleigh Region	1	0	0	PO Box 52382		Durham	NC	27717				PO Box 52382		Durham	NC	27717				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.experiencehealthnc.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.experiencehealthnc.com	www.experiencehealthnc.com
H3794	002	0	2021	01	UnitedHealthcare Dual Complete LP1 (HMO D-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H3800	001	0	2021	01	Provider Partners Illinois Advantage Plan (HMO I-SNP)	Illinois (partial)		Illinois (partial)	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H3805	001	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select counties in Western Oregon		Select counties in Western Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	007	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Benton, Lane, and Linn counties		Benton, Lane, and Linn counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	015	0	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Select counties in Western Washington		Select counties in Western Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	016	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Clark and Cowlitz counties		Clark and Cowlitz counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	017	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	King county		King county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	019	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Kitsap and Pierce Counties		Kitsap and Pierce Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	020	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Island and Snohomish counties		Island and Snohomish counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	021	0	2021	01	AARP Medicare Advantage (HMO)	Skagit and Whatcom Counties		Skagit and Whatcom Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	023	1	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Benton, Lane, and Linn counties		Benton and Lane counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	023	2	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Benton, Lane, and Linn counties		Linn county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	025	1	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Thurston and Lewis Counties		Lewis county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	025	2	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Thurston and Lewis Counties		Thurston county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	029	0	2021	01	AARP Medicare Advantage (HMO)	Yakima county		Yakima county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	030	0	2021	01	AARP Medicare Advantage Walgreens (HMO)	Clark county		Clark county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	032	0	2021	02	AARP Medicare Advantage Walgreens (HMO-POS)	Snohomish county		Snohomish county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	033	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Spokane County		Spokane County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	034	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Spokane county		Spokane county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	035	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	Spokane county		Spokane county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	036	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select counties in Western Oregon		Select counties in Western Oregon	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	037	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select counties in western Washington		Select counties in western Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $185.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $185.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H3805	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	OR Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	OR Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3805	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	OR Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	OR Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3805	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	OR Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	OR Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3805	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Washington		Select counties in Washington	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	610097	9999	www.UHCMedicareSolutions.com
H3805	806	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Washington		Select counties in Washington	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3805	807	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Washington		Select counties in Washington	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H3809	001	0	2021	20	Providence ElderPlace Portland (dual eligible) (PACE)	Portland Metro area and North Coast		Portland Metro area and North Coast	1	3	0									4400 NE Halsey, Building 1, Suite 200		Portland	OR	97213				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.providence.org/elderplace	0	0	1			0					3	0	0		http://oregon.providence.org/our-services/p/providence-long-term-care-pharmacy-for-clinicians-hp/ove	http://oregon.providence.org/our-services/p/providence-elderplace-prescription-medications/
H3809	002	0	2021	20	Providence ElderPlace Portland (private pay) (PACE)	Portland Metro area and North Coast		Portland Metro area and North Coast	1	3	0									4400 NE Halsey, Building 1, Suite 200		Portland	OR	97213				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.providence.org/elderplace	0	0	1			0					3	0	0		http://oregon.providence.org/our-services/p/providence-long-term-care-pharmacy-for-clinicians-hp/ove	http://oregon.providence.org/our-services/p/providence-elderplace-prescription-medications/
H3810	001	0	2021	01	AllCare Advantage Gold (HMO)	Josephine, Jackson, Douglas*		Josephine, Jackson, Douglas*	1	0	0	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com									5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AllCareHealth.com/Advantage	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AllCareHealth.com/Advantage/Providers	www.AllCareHealth.com/Advantage/Pharmacy	www.allcarehealth.com/medicare/allcare-advantage-2019/lookup-tools/formulary-search
H3810	003	0	2021	01	AllCare Advantage Gold Plus Rx (HMO)	Josephine, Jackson, Douglas*		Josephine, Jackson, Douglas*	1	0	0	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AllCareHealth.com/Advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AllCareHealth.com/Advantage/Providers	www.AllCareHealth.com/Advantage/Pharmacy	www.AllCareHealth.com/Advantage/Formulary
H3810	020	0	2021	01	AllCare Advantage Preferred Rx (HMO)	Josephine, Jackson, Douglas*		Josephine, Jackson, Douglas*	1	0	0	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.AllCareHealth.com/Advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AllCareHealth.com/Advantage/Providers	www.AllCareHealth.com/Advantage/Pharmacy	www.AllCareHealth.com/Advantage/Formulary
H3810	021	0	2021	01	AllCare Advantage Focus (HMO)	Josephine, Jackson, Douglas*		Josephine, Jackson, Douglas*	1	0	0	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com									5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AllCareHealth.com/Advantage	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AllCareHealth.com/Advantage/Providers	www.AllCareHealth.com/Advantage/Pharmacy	www.allcarehealth.com/medicare/allcare-advantage-2019/lookup-tools/formulary-search
H3810	022	0	2021	01	AllCare Advantage Focus Rx (HMO)	Josephine, Jackson, Douglas*		Josephine, Jackson, Douglas*	1	0	0	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com	1701 NE 7th Street		Grants Pass	OR	97526		freddy.sennhauser@allcarehealth.com	sheila.anders@allcarehealth.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AllCareHealth.com/Advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AllCareHealth.com/Advantage/Providers	www.AllCareHealth.com/Advantage/Pharmacy	www.AllCareHealth.com/Advantage/Formulary
H3811	001	0	2021	01	Samaritan Advantage Conventional Plan (HMO)	Benton, Lincoln and Linn counties		Benton, Lincoln and Linn counties	1	0	0	2300 NW Walnut Boulevard		Corvallis	OR	97330												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://medicare.samhealthplans.org	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org
H3811	002	0	2021	01	Samaritan Advantage Premier Plan (HMO)	Benton, Lincoln and Linn counties		Benton, Lincoln and Linn counties	1	0	0	2300 NW Walnut Boulevard		Corvallis	OR	97330				2300 NW Walnut Boulevard		Corvallis	OR	97330				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://medicare.samhealthplans.org	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org
H3811	003	0	2021	01	Samaritan Advantage Special Needs Plan (HMO D-SNP)	Benton, Linn and Lincoln counties		Benton, Linn and Lincoln counties	1	0	0	2300 NW Walnut Boulevard		Corvallis	OR	97330				2300 NW Walnut Boulevard		Corvallis	OR	97330				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	https://medicare.samhealthplans.org	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org
H3811	009	0	2021	01	Samaritan Advantage Premier Plan Plus (HMO)	Benton, Lincoln, and Linn counties		Benton, Lincoln, and Linn counties	1	0	0	2300 NW Walnut Boulevard		Corvallis	OR	97330				2300 NW Walnut Boulevard		Corvallis	OR	97330				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://medicare.samhealthplans.org	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org	https://medicare.samhealthplans.org
H3813	001	0	2021	04	Moda Health PPO (PPO)	Western Oregon		Western Oregon	1	0	0	PO Box 40384	Attn:  Moda Health PPO	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com									5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	009	0	2021	04	Moda Health PPORX Enhanced (PPO)	Greater Portland Metro		Greater Portland Metro	1	0	0	PO Box 40384	Attn:  Moda Health PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	PO Box 40327	Attn:  Moda Health PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	010	0	2021	04	Moda Health Central PPORX (PPO)	Central Oregon		Central Oregon	1	0	0	PO Box 40384	Attn:  Moda Health PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	PO Box 40327	Attn:  Moda Health PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	011	0	2021	04	Moda Health NW PPORX (PPO)	Northwest Oregon		Northwest Oregon	1	0	0	PO Box 40384	Attn:  Moda Health PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	PO Box 40327	Attn:  Moda Health PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	012	0	2021	04	Moda Health Southern PPORX (PPO)	Southern Oregon		Southern Oregon	1	0	0	PO Box 40384	Attn:  Moda Health PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	PO Box 40327	Attn:  Moda Health PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	013	0	2021	04	Moda Health Metro PPORX (PPO)	Greater Portland Metro		Greater Portland Metro	1	0	0	PO Box 40384	Attn:  Moda Health PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	PO Box 40327	Attn:  Moda Health PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	014	0	2021	04	Moda Health Mid-valley PPORX (PPO)	Mid-West Oregon		Mid-West Oregon	1	0	0	P.O. Box 40384	ATTN: MODA HEALTH PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	P.O. Box 40327	ATTN: MODA HEALTH PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3813	804	0	2021	04	Moda Health Group Plan + Rx (PPO)	Statewide		Statewide	1	3	1	PO Box 40384	Attn:  Moda Health PPORX	Portland	OR	97240		MedicalMedicare@modahealth.com	MedicalMedicare@modahealth.com	P.O. Box 40327	Attn:  Moda Health PPORX	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com	5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.modahealth.com/medicare	www.modahealth.com/medicare	www.modahealth.com/medicare
H3814	007	0	2021	01	ATRIO Special Needs Plan (HMO D-SNP)	Douglas and Klamath Counties	ATRIO Special Needs Plan (HMO D-SNP)	Douglas and Klamath Counties	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H3815	001	0	2021	01	My Choice (HMO)	LA, Orange, San Bernardino & Riverside Counties		LA, Orange, San Bernardino & Riverside Counties	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	006	0	2021	01	My Choice (HMO)	Stanislaus, San Joaquin Counties		Stanislaus, San Joaquin Counties	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	007	0	2021	01	My Choice (HMO)	Santa Clara & San Francisco		Santa Clara & San Francisco	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	008	0	2021	01	Platinum (HMO)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	009	0	2021	01	CalPlus (HMO)	SoCal & NorCal		SoCal & NorCal	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	010	0	2021	01	Heart & Diabetes (HMO C-SNP)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	1	4	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	011	0	2021	01	AllCare Preferred Plan (HMO)	Stanislaus County		Stanislaus County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	013	0	2021	01	smartHMO (HMO)	Los Angeles County		Los Angeles County	1	0	0	1100 W Town and Country Rd., Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd., Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	015	0	2021	01	Platinum (HMO)	San Bernardino and Riverside Counties		San Bernardino and Riverside Counties	1	0	0	1100 W Town and Country Rd., Suite 1300		Orange	CA	92868		otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd., Suite 1300		Orange	CA	92868		otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	016	0	2021	01	Platinum (HMO)	San Diego		San Diego	1	0	0	1100 W Town and Country Rd., Suite 1300		Orange	CA	92868		otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd., Suite 1300		Orange	CA	92868		otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	018	0	2021	01	Platinum (HMO)	Marin County		Marin County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	019	0	2021	01	Sutter Advantage (HMO)	Sacramento, Placer & Yolo Counties		Sacramento, Placer & Yolo Counties	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	020	0	2021	01	Sutter Advantage (HMO)	Santa Clara County		Santa Clara County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	021	0	2021	01	Sutter Advantage (HMO)	Santa Cruz County		Santa Cruz County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	022	0	2021	01	Sutter Advantage (HMO)	San Mateo County		San Mateo County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	023	0	2021	01	Sutter Advantage (HMO)	Sonoma County		Sonoma County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	024	0	2021	01	Sutter Advantage (HMO)	San Francisco County		San Francisco County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	025	0	2021	01	Platinum (HMO)	San Joaquin		San Joaquin	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	026	0	2021	01	AVA (HMO)	Santa Clara		Santa Clara	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	027	0	2021	01	AVA (HMO)	SD, LA, OC, SLO and Ventura		SD, LA, OC, SLO and Ventura	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	028	0	2021	01	My Choice (HMO)	San Luis Obispo		San Luis Obispo	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	029	0	2021	01	My Choice (HMO)	Ventura		Ventura	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	030	0	2021	01	CalPlusDuals (HMO D-SNP)	ST, SJ, Marin		ST, SJ, Marin	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	031	0	2021	01	Harmony (HMO)	San Diego, Santa Clara		San Diego, Santa Clara	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	032	0	2021	01	Select (HMO)	San Diego		San Diego	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	801	0	2021	01	Retiree Options (HMO)	Southern California and Northern California		Southern California and Northern California	1	3	1	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwent@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3815	802	0	2021	01	Retiree Option (HMO)	Northern and Southern California		Northern and Southern California	1	3	1	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H3817	008	1	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Select Counties in Oregon/Clark Co, WA		Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	008	2	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Select Counties in Oregon/Clark Co, WA		Non-Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	009	1	2021	04	Regence MedAdvantage + Rx Enhanced (PPO)	Select Counties in Oregon/Clark Co, WA		Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	009	2	2021	04	Regence MedAdvantage + Rx Enhanced (PPO)	Select Counties in Oregon/Clark Co, WA		Non-Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	010	0	2021	04	Regence Valiance (PPO)	Select Counties in Oregon/Clark Co, WA		Select Counties in Oregon/Clark Co, WA	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	011	1	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Select Counties in Oregon/Clark Co, WA		Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	011	2	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Select Counties in Oregon/Clark Co, WA		Non-Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	801	0	2021	04	Regence MedAdvantage (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	802	0	2021	04	Regence MedAdvantage + Rx (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	803	0	2021	04	Regence MedAdvantage + Rx 02 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3817	804	0	2021	04	Regence MedAdvantage + Rx 03 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H3822	001	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	Chicago Metro Area		Chicago Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H3822	002	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	Bernalillo, Sandoval, Torrance and Valencia cntys		Bernalillo, Sandoval, Torrance and Valencia cntys	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/mapd	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluenm.com/mapd/providers	www.getbluenm.com/mapd/pharmacies	www.getbluenm.com/mapd/druglist
H3822	007	0	2021	02	Blue Cross Medicare Advantage Basic Plus (HMO-POS)	Chicago Metro Area		Chicago Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.getblueil.com/mapd	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H3822	008	0	2021	02	Blue Cross Medicare Advantage Premier Plus (HMO-POS)	Chicago Metro Area		Chicago Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.getblueil.com/mapd	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H3822	012	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	Springfield and Central Illinois		Springfield and Central Illinois	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H3822	801	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Illinois		Statewide in Illinois	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	802	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in New Mexico		Statewide in New Mexico	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	805	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Illinois		Statewide in Illinois	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	806	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in New Mexico		Statewide in New Mexico	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	809	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Illinois		Statewide in Illinois	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	810	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in New Mexico		Statewide in New Mexico	1	3	1	PO Box 4555		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	813	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	State of MT		State of MT	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	814	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	State of MT		State of MT	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3822	815	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Montana		Statewide in Montana	1	3	1	PO Box 4555		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H3832	007	0	2021	04	HMSA Akamai Advantage Standard (PPO)	Hawaii, Kalawao, Kauai and Maui counties		Hawaii, Kalawao, Kauai and Maui counties	1	0	0	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	008	0	2021	04	HMSA Akamai Advantage Standard Plus (PPO)	Hawaii, Kalawao, Kauai and Maui counties		Hawaii, Kalawao, Kauai and Maui counties	1	0	0	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	009	0	2021	04	HMSA Akamai Advantage Complete (PPO)	Honolulu County		Honolulu County	1	0	0	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	010	0	2021	04	HMSA Akamai Advantage Complete Plus (PPO)	Honolulu County		Honolulu County	1	0	0	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	011	0	2021	04	HMSA Akamai Advantage Dual Care (PPO D-SNP)	Hawaii, Kalawao, Kauai, Maui and Honolulu counties		Hawaii, Kalawao, Kauai, Maui and Honolulu counties	1	0	0	AMS	PO Box 860	Honolulu	HI	96808				AMS	PO Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	801	0	2021	04	HMSA Akamai Advantage EGWP with Drug CY (PPO)	National		National	1	3	1	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	802	0	2021	04	HMSA Akamai Advantage EGWP with Drug NCY (PPO)	National		National	1	3	1	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	805	0	2021	04	HMSA Akamai Advantage EGWP CY (PPO)	National		National	1	3	1	AMS	P.O. Box 860	Honolulu	HI	96808												7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3832	807	0	2021	04	HMSA Akamai Advantage Union Group Plan MAPD (PPO)	National		National	1	3	1	AMS	P.O. Box 860	Honolulu	HI	96808				AMS	P.O. Box 860	Honolulu	HI	96808				7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com/advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.hmsa.com/advantage	www.hmsa.com/advantage	www.hmsa.com/advantage
H3864	002	0	2021	01	PacificSource Medicare Essentials 2 (HMO)	Central, Eastern, Mid-Columbia Gorge, Lane		Central, Eastern, Mid-Columbia Gorge, Lane	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	006	0	2021	01	PacificSource Medicare Essentials Rx 6 (HMO)	Central, Eastern Oregon and Mid-Columbia Gorge		Central, Eastern Oregon and Mid-Columbia Gorge	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	014	0	2021	02	PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)	Central, Eastern Oregon and Mid-Columbia Gorge		Central, Eastern Oregon and Mid-Columbia Gorge	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	021	0	2021	01	PacificSource Medicare Essentials Rx 21 (HMO)	Eastern Idaho		Eastern Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	024	0	2021	02	PacificSource Medicare MyCare Choice Rx 24 (HMO-POS)	Southwest and Southern Idaho		Southwest and Southern Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	027	0	2021	01	PacificSource Medicare Essentials Rx 27 (HMO)	Central, Eastern Oregon and Mid-Columbia Gorge		Central, Eastern Oregon and Mid-Columbia Gorge	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $399.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $399.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	029	0	2021	02	PacificSource Medicare MyCare Choice Rx 29 (HMO-POS)	Yellowstone County		Yellowstone County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	030	0	2021	01	PacificSource Medicare MyCare 30 (HMO)	Yellowstone County		Yellowstone County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	032	0	2021	01	PacificSource Medicare MyCare Rx 32 (HMO)	Southwest Idaho		Southwest Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	033	0	2021	01	PacificSource Medicare MyCare Rx 33 (HMO)	Spokane County		Spokane County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	034	0	2021	01	PacificSource Medicare MyCare Rx 34 (HMO)	Pierce County		Pierce County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	035	0	2021	01	PacificSource Medicare MyCare 35 (HMO)	Spokane and Pierce Counties		Spokane and Pierce Counties	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	036	0	2021	01	PacificSource Medicare Essentials Rx 36 (HMO)	Lane County		Lane County	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	037	0	2021	01	PacificSource Medicare MyCare Rx 37 (HMO)	Clark County		Clark County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	038	0	2021	01	PacificSource Medicare MyCare Rx 38 (HMO)	Clark County		Clark County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	039	0	2021	01	PacificSource Medicare MyCare Rx 39 (HMO)	Portland Area		Portland Area	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	040	0	2021	01	PacificSource Medicare MyCare Rx 40 (HMO)	Portland Area		Portland Area	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	041	0	2021	01	PacificSource Medicare Essentials Rx 41 (HMO)	Coos, Curry and Lane Counties		Coos, Curry and Lane Counties	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	801	0	2021	01	PacificSource Medicare Essentials 801 (HMO)	Statewide - Idaho, Montana, Oregon and Washington		Statewide - Idaho, Montana, Oregon and Washington	1	3	1	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	803	0	2021	01	PacificSource Medicare Essentials Rx 803 (HMO)	Statewide - Idaho, Montana, Oregon and Washington		Statewide - Idaho, Montana, Oregon and Washington	1	3	1	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	805	0	2021	02	PacificSource Medicare Essentials 805 (HMO-POS)	Statewide - Idaho, Montana, Oregon and Washington		Statewide - Idaho, Montana, Oregon and Washington	1	3	1	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3864	806	0	2021	02	PacificSource Medicare Essentials Rx 806 (HMO-POS)	Statewide - Idaho, Montana, Oregon and Washington		Statewide - Idaho, Montana, Oregon and Washington	1	3	1	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H3890	001	0	2021	04	Johns Hopkins Advantage MD (PPO)	Counties: AA BL BC CV CR FR HW SS WH WC WR		Counties: AA BL BC CV CR FR HW SS WH WC WR	1	0	0	P.O. Box 3538		Scranton	PA	18505				P.O. Box 3538		Scranton	PA	18505				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hopkinsmedicare.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/
H3890	002	0	2021	04	Johns Hopkins Advantage MD Plus (PPO)	Counties: AA BL BC CV CR FR HW SS WH WC WR		Counties: AA BL BC CV CR FR HW SS WH WC WR	1	0	0	P.O. Box 3538		Scranton	PA	18505				P.O. Box 3538		Scranton	PA	18505				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hopkinsmedicare.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/
H3890	004	0	2021	04	Johns Hopkins Advantage MD Premier (PPO)	Montgomery County		Montgomery County	1	0	0	P.O. Box 3538		Scranton	PA	18505				P.O. Box 3538		Scranton	PA	18505				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hopkinsmedicare.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/	www.hopkinsmedicare.com/
H3890	801	0	2021	04	Johns Hopkins Advantage MD Group Plan CY (PPO)	DC, DE, FL, GA, MD, NC, PA, SC, VA		DC, DE, FL, GA, MD, NC, PA, SC, VA	1	3	1	P.O. Box 3538		Scranton	PA	18505				P.O. Box 3538		Scranton	PA	18505				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopkinsmedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.hopkinsmedicare.com	www.hopkinsmedicare.com	www.hopkinsmedicare.com
H3907	002	0	2021	01	UPMC for Life HMO No Rx (HMO)	Western and North Eastern Pennsylvania		Western and North Eastern Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu									2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	2	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	006	0	2021	01	UPMC for Life HMO Rx Enhanced (HMO)	Western and North Eastern PA		Western and North Eastern PA	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	029	0	2021	01	UPMC for Life HMO Rx (HMO)	Western, Central, and North Eastern PA		Western, Central, and North Eastern PA	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	037	0	2021	01	UPMC for Life HMO Deductible with Rx (HMO)	Western, Central, and North Eastern PA		Western, Central, and North Eastern PA	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	045	0	2021	01	UPMC for Life HMO Premier Rx (HMO)	Berks County		Berks County	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	046	0	2021	01	UPMC for Life HMO Premier Rx (HMO)	South Western and North Central Pennsylvania		South Western and North Central Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	047	0	2021	01	UPMC for Life HMO Rx (HMO)	Berks County		Berks County	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	049	0	2021	01	UPMC for Life HMO Rx Choice (HMO)	Western Pennsylvania		Western Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	050	0	2021	01	UPMC for Life HMO Premier Rx (HMO)	Erie, Lawrence, Mercer, Venango Counties		Erie, Lawrence, Mercer, Venango Counties	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	051	0	2021	01	UPMC for Life HMO Premier Rx (HMO)	Westmoreland County		Westmoreland County	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	052	0	2021	01	UPMC for Life HMO Premier Rx (HMO)	Cumberland, Dauphin, Lancaster, and York Counties		Cumberland, Dauphin, Lancaster, and York Counties	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	801	0	2021	01	UPMC Employer Group (HMO)	Western Pennsylvania		Western Pennsylvania	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu									2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	2	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	802	0	2021	01	UPMC Employer Group Rx (HMO)	Western Pennsylvania		Western Pennsylvania	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3907	803	0	2021	01	UPMC Employer Group Rx (HMO)	Western Pennsylvania		Western Pennsylvania	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	http://www.upmchealthplan.com/medicare	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H3908	001	0	2021	20	Trinity Health LIFE Pennsylvania (PACE)	Counties: PHL (partial), DelCo (partial)		Counties: PHL (partial), DelCo (partial)	1	3	0									4508 CHESTNUT STREET		Philadelphia	PA	19139				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.mercylife-westphila.org	0	0	1			0					3	0	0		www.CareKinesis.com	www.trinityhealthpace.org
H3908	002	0	2021	20	Trinity Health LIFE Pennsylvania (PACE)	Counties: PHL (partial), DelCo (partial)		Counties: PHL (partial), DelCo (partial)	1	3	0									4508 Chestnut Street		Philadelphia	PA	19139				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.trinityhealthpace.org	0	0	1			0					3	0	0		www.CareKinesis.com	www.trinityhealthpace.org
H3909	001	0	2021	04	Personal Choice 65 Rx (PPO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O Box 13713		Philadelphia	PA	19101				P.O Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3909	007	0	2021	04	Personal Choice 65 Medical Only (PPO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3909	009	0	2021	04	Personal Choice 65 Rx (PPO)	Chester, Delaware, Montgomery Counties		Chester, Delaware, Montgomery Counties	1	0	0	P.O Box 13713		Philadelphia	PA	19101				P.O Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3909	014	0	2021	04	Personal Choice 65 Prime Rx (PPO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O Box 13713		Philadelphia	PA	19101				P.O Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3909	015	0	2021	04	Personal Choice 65 Prime Rx (PPO)	Chester, Delaware, Montgomery Counties		Chester, Delaware, Montgomery Counties	1	0	0	P.O Box 13713		Philadelphia	PA	19101				P.O Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3909	801	0	2021	04	Personal Choice 65 Group Medical Only (PPO)	National		National	1	3	1	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3909	802	0	2021	04	Personal Choice 65 Group Rx (PPO)	National		National	1	3	1	P.O Box 13713		Philadelphia	PA	19101				P.O Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3916	001	0	2021	04	Freedom Blue PPO Classic (PPO)	Southwestern PA		Southwestern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	002	0	2021	04	Freedom Blue PPO Classic (PPO)	West Central PA		West Central PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	005	0	2021	04	Freedom Blue PPO Deluxe (PPO)	Central and Northeastern PA		Central and Northeastern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	012	0	2021	04	Freedom Blue PPO Basic (PPO)	Central and Northeastern PA		Central and Northeastern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	015	0	2021	04	Freedom Blue PPO Standard (PPO)	Central and Northeastern PA		Central and Northeastern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	018	0	2021	04	Freedom Blue PPO ValueRx (PPO)	Central and Northeastern PA		Central and Northeastern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	022	0	2021	04	Freedom Blue PPO Select (PPO)	Southwestern PA		Southwestern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	024	0	2021	04	Freedom Blue PPO Select (PPO)	West Central PA		West Central PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	032	0	2021	04	Freedom Blue PPO ValueRx (PPO)	Southwestern PA		Southwestern PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	033	0	2021	04	Freedom Blue PPO ValueRx (PPO)	West Central PA		West Central PA	1	0	0	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	034	1	2021	04	Community Blue Medicare PPO Distinct (PPO)	North Central PA		Lehigh Valley	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	034	3	2021	04	Community Blue Medicare PPO Distinct (PPO)	North Central PA		South Central PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	034	4	2021	04	Community Blue Medicare PPO Distinct (PPO)	North Central PA		North Central	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	034	5	2021	04	Community Blue Medicare PPO Distinct (PPO)	North Central PA		Lancaster	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	035	1	2021	04	Complete Blue PPO Distinct (PPO)	Western PA		Southwest PA	1	0	0	Complete Blue PPO	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Complete Blue PPO	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	035	2	2021	04	Complete Blue PPO Distinct (PPO)	Western PA		West Central PA	1	0	0	Complete Blue PPO	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Complete Blue PPO	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	036	0	2021	04	Community Blue Medicare Plus PPO Distinct (PPO)	Counties: TA, LG, SN, CN		Counties: TA, LG, SN, CN	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	037	1	2021	04	Community Blue Medicare PPO Signature (PPO)	Central PA		Lehigh Valley PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	037	2	2021	04	Community Blue Medicare PPO Signature (PPO)	Central PA		South Central PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	037	3	2021	04	Community Blue Medicare PPO Signature (PPO)	Central PA		NEPA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	037	4	2021	04	Community Blue Medicare PPO Signature (PPO)	Central PA		Lancaster PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	038	0	2021	04	Community Blue Medicare PPO Signature (PPO)	Northwestern PA		Northwestern PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	039	0	2021	04	Community Blue Medicare Plus PPO Signature (PPO)	Counties: TA, CN, LG, SN		Counties: TA, CN, LG, SN	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	801	0	2021	04	Freedom Blue PPO MA PA CALENDAR (PPO)	Pennsylvania		Pennsylvania	1	3	1	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	802	0	2021	04	Freedom Blue PPO MAPD PA CALENDAR (PPO)	Pennsylvania		Pennsylvania	1	3	1	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	804	0	2021	04	Freedom Blue PPO MAPD PA Non-Calendar (PPO)	Pennsylvania		Pennsylvania	1	3	1	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Freedom Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	805	0	2021	04	Community Blue Medicare PPO MA PA Calendar (PPO)	Pennsylvania		Pennsylvania	1	3	1	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	806	0	2021	04	Community Blue Medicare PPO PA MAPD Calendar (PPO)	Pennsylvania		Pennsylvania	1	3	1	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3916	807	0	2021	04	Community Blue Medicare Plus PPO MAPD Calendar (PPO)	Pennsylvania		Pennsylvania	1	3	1	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3917	001	0	2021	20	Community LIFE (PACE)	Alleghny Westmrlnd Washingtn part, Bedford, Fulton		Alleghny Westmrlnd Washingtn part, Bedford, Fulton	1	3	0									SUITE # 700	2400 ARDMORE BOULEVARD	PITTSBURGH	PA	15221				2100001200200001200300001200400001200500001200600001200700001200	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.commlife.org/	0	0	1			0					3	0	0		www.commlife.org	www.commlife.org
H3917	002	0	2021	20	Community LIFE (PACE)	Alleghny Westmrlnd Washingtn part, Bedford, Fulton		Alleghny Westmrlnd Washingtn part, Bedford, Fulton	1	3	0									SUITE # 700	2400 ARDMORE BOULEVARD	PITTSBURGH	PA	15221				2100001200200001200300001200400001200500001200600001200700001200	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.commlife.org/	0	0	1			0					3	0	0		www.commlife.org	www.commlife.org
H3918	001	0	2021	20	LIFE Pittsburgh Dual Eligibles Pharmacy (PACE)	Partial Allegheny*		Partial Allegheny*	1	3	0									875 Greentree Road	One Parkway Center, Suite 200	Pittsburgh	PA	15220		Akrchmar@lifepittsburgh.org	Akrchmar@lifepittsburgh.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	LIFEPittsburgh.org	0	0	1			0					3	0	0		none	notapplicable--noformulary
H3918	002	0	2021	20	LIFE Pittsburgh Medicare Only Pharmacy (PACE)	Partial Allegheny *		Partial Allegheny *	1	3	0									875 Greentree Road	One Parkway Center, Suite 200	Pittsburgh	PA	15220		Akrchmar@lifepittsburgh.org	Akrchmar@lifepittsburgh.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	LIFEPittsburgh.org	0	0	1			0					3	0	0		none	notapplicable--noformulary
H3919	001	0	2021	20	Mercy LIFE (PACE)	Delaware County & Partial PHL, Montco, Chester		Delaware County & Partial PHL, Montco, Chester	1	3	0									1930 S. Broad Street, Suite 3		Philadelphia	PA	19145				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mercylife.org	0	0	1			0					3	0	0		www.mercylife.org	www.mercylife.org
H3919	002	0	2021	20	Mercy LIFE (PACE)	Delaware County & Partial PHL, Montco, Chester		Delaware County & Partial PHL, Montco, Chester	1	3	0									1930 S. Broad Street, Suite 3		Philadelphia	PA	19145				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mercylife.org	0	0	1			0					3	0	0		www.mercylife.org	www.mercylife.org
H3923	013	0	2021	04	BlueJourney Classic (PPO)	21 Counties in Central PA		21 Counties in Central PA	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	017	0	2021	04	BlueJourney Prime (PPO)	21 Counties in Central PA		21 Counties in Central PA	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	028	0	2021	04	BlueJourney Select (PPO)	21 Counties in Central PA		21 Counties in Central PA	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	801	0	2021	04	BlueJourney Group PPO Silver Rx (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	802	0	2021	04	BlueJourney Group PPO Without Rx (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	2	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	803	0	2021	04	BlueJourney Group PPO Bronze Rx FY (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	817	0	2021	04	BlueJourney Group PPO Gold Rx (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	818	0	2021	04	BlueJourney Group PPO Platinum Rx (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	819	0	2021	04	BlueJourney Group PPO Bronze Rx (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	820	0	2021	04	BlueJourney Group PPO Platinum Rx FY (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	821	0	2021	04	BlueJourney Group PPO Gold Rx FY (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3923	822	0	2021	04	BlueJourney Group PPO Silver Rx FY (PPO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantageppo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3924	059	13	2021	04	Geisinger Gold Preferred Advantage Rx (PPO)	Pennsylvania		Midstate	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	059	14	2021	04	Geisinger Gold Preferred Advantage Rx (PPO)	Pennsylvania		Central	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	059	15	2021	04	Geisinger Gold Preferred Advantage Rx (PPO)	Pennsylvania		Bucks, Carbon, Lehigh, Monroe, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	059	16	2021	04	Geisinger Gold Preferred Advantage Rx (PPO)	Pennsylvania		Midwest	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	059	17	2021	04	Geisinger Gold Preferred Advantage Rx (PPO)	Pennsylvania		Midsouth	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	059	18	2021	04	Geisinger Gold Preferred Advantage Rx (PPO)	Pennsylvania		Adams, Franklin, Lebanon, York	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	060	13	2021	04	Geisinger Gold Preferred Complete Rx (PPO)	Pennsylvania		Midstate	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	060	14	2021	04	Geisinger Gold Preferred Complete Rx (PPO)	Pennsylvania		Central	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	060	15	2021	04	Geisinger Gold Preferred Complete Rx (PPO)	Pennsylvania		Bucks, Carbon, Lehigh, Monroe, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	060	16	2021	04	Geisinger Gold Preferred Complete Rx (PPO)	Pennsylvania		Midwest	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	060	17	2021	04	Geisinger Gold Preferred Complete Rx (PPO)	Pennsylvania		Midsouth	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	060	18	2021	04	Geisinger Gold Preferred Complete Rx (PPO)	Pennsylvania		Adams, Franklin, Lebanon, York	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3924	062	21	2021	04	Geisinger Gold Preferred Enhanced Rx (PPO)	Pennsylvania		Pennsylvania Mountains & Valleys	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	GeisingerGold.com	GeisingerGold.com	GeisingerGold.com
H3924	062	22	2021	04	Geisinger Gold Preferred Enhanced Rx (PPO)	Pennsylvania		Pennsylvania Heartland	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	GeisingerGold.com	GeisingerGold.com	GeisingerGold.com
H3924	064	1	2021	04	Geisinger Gold Preferred 360 Rx (PPO)	Adams, York, Lehigh, Northampton		Adams, York	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	GeisingerGold.com	GeisingerGold.com	GeisingerGold.com
H3924	064	2	2021	04	Geisinger Gold Preferred 360 Rx (PPO)	Adams, York, Lehigh, Northampton		Lehigh, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	GeisingerGold.com	GeisingerGold.com	GeisingerGold.com
H3924	804	0	2021	04	Geisinger Gold Preferred Rx Employer Group Plan (PPO)	Pennsylvania		Pennsylvania	1	3	1	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3925	001	0	2021	20	Senior LIFE Johnstown Dual Eligible (PACE)	Cambria and Somerset Counties		Cambria and Somerset Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H3925	002	0	2021	20	Senior LIFE Johnstown Medicare Only (PACE)	Cambria and Somerset Counties		Cambria and Somerset Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifejohnstown.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H3928	001	0	2021	01	Aetna Medicare Advantra Plan (HMO)	New Orleans - Baton Rouge Metro Parishes		New Orleans - Baton Rouge Metro Parishes	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3928	002	0	2021	01	Aetna Medicare Advantra Plan (HMO)	Bossier, Caddo and St. Tammany Parishes		Bossier, Caddo and St. Tammany Parishes	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3928	801	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Louisiana		Louisiana	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3928	803	0	2021	01	Aetna Medicare Plan (HMO)	Louisiana		Louisiana	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	004	0	2021	01	Aetna Medicare Premier Plus (HMO)	Southeast Pennsylvania		Southeast Pennsylvania	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	064	0	2021	01	Aetna Medicare Premier (HMO)	Southeast Pennsylvania		Southeast Pennsylvania	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	070	0	2021	01	Aetna Medicare Silver (HMO)	Pennsylvania		Pennsylvania	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	091	0	2021	01	Aetna Medicare PinnacleHealth Prime (HMO)	Cumberland and Dauphin counties		Cumberland and Dauphin counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	092	0	2021	01	Aetna Medicare Prime Plan (HMO)	Maricopa County		Maricopa County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	093	0	2021	01	Aetna Medicare Prime (HMO)	Denver Metro		Denver Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	094	0	2021	01	Aetna Medicare Select Plan (HMO)	Clark County		Clark County	1	0	0	P.O Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	095	0	2021	01	Aetna Medicare Standard Plan (HMO)	District of Columbia		District of Columbia	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	096	0	2021	01	Aetna Medicare Prime Plan (HMO)	Fairfax County and Surrounding Area		Fairfax County and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	097	0	2021	01	Aetna Medicare Connect Plus (HMO)	Southern Maryland		Southern Maryland	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $255.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $255.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	098	0	2021	01	Aetna Medicare Select Plan (HMO)	Richmond and Surrounding Area		Richmond and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	099	0	2021	01	Aetna Medicare Select Plan (HMO)	Danville and Surrounding Area		Danville and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	100	0	2021	01	Aetna Medicare Select Plan (HMO)	Newport News and Surrounding Area		Newport News and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	101	0	2021	01	Aetna Medicare Select Plan (HMO)	Roanoke and Surrounding Area		Roanoke and Surrounding Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	102	0	2021	01	Aetna Medicare Premier Plus (HMO)	New Castle, Kent and Sussex Counties		New Castle, Kent and Sussex Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	104	0	2021	01	Aetna Medicare Elite (HMO)	New Castle, Kent and Sussex Counties		New Castle, Kent and Sussex Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	105	0	2021	01	Aetna Medicare Main Line Health Prime (HMO)	Chester, Delaware and Montgomery counties		Chester, Delaware and Montgomery counties	1	0	0	P.O. Box 7405		London	KY	40724		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	107	0	2021	01	Aetna Medicare Value Plan (HMO)	Northeastern and Youngstown Area		Northeastern and Youngstown Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	108	0	2021	01	Aetna Medicare Value Plan (HMO)	Central Ohio Area		Central Ohio Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	109	0	2021	01	Aetna Medicare Value (HMO)	Toledo and Cincinnati Area		Toledo and Cincinnati Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	112	0	2021	01	Aetna Medicare Elite (HMO)	Southeastern and Central Pennsylvania		Southeastern and Central Pennsylvania	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	115	0	2021	01	Aetna Medicare Platinum Plan (HMO)	Carson City, Douglas and Washoe Counties		Carson City, Douglas and Washoe Counties	1	0	0	P.O Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	118	0	2021	01	Aetna Medicare Value Plan (HMO)	Lexington Area		Lexington Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	124	0	2021	01	Aetna Medicare UVA Health System Prime (HMO)	Charlottesville and Surrounding area		Charlottesville and Surrounding area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	126	0	2021	01	Aetna Medicare Value Plan (HMO)	Puget Sound		Puget Sound	1	0	0	P.O Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	129	0	2021	01	Aetna Medicare Platinum Plan (HMO)	Pima and Pinal Counties		Pima and Pinal Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	130	0	2021	01	Aetna Medicare Platinum Plan (HMO)	Maricopa county		Maricopa county	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	131	0	2021	01	Aetna Medicare Platinum Plan (HMO)	Gila, Mohave and Yavapai Counties		Gila, Mohave and Yavapai Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	133	0	2021	01	Aetna Medicare Value Plan (HMO)	Louisville Area		Louisville Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	134	0	2021	01	Aetna Medicare Value Plan (HMO)	Bowling Green/Southwest KY Area		Bowling Green/Southwest KY Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	140	0	2021	01	Aetna Medicare Value Plan (HMO)	Ashland Area		Ashland Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	801	0	2021	01	Aetna Medicare Plan (HMO)	Pennsylvania		Pennsylvania	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3931	804	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Pennsylvania		Pennsylvania	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3942	001	0	2021	20	Elderhaus PACE (PACE)	Elderhaus PACE-New Hanover County		Elderhaus PACE-New Hanover County	1	3	0									2222 S. 17th Street		Wilmington	NC	28401		kelly.valade@elderhaus.com	kelly.valade@elderhaus.com	2000000000207301730307301730407301730507301730607301730000000000	2000000000207301730307301730407301730507301730607301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.elderhaus.com	0	0	1			0					3	0	0		www.elderhaus.com	www.elderhaus.com
H3942	002	0	2021	20	Elderhaus PACE (PACE)	Elderhaus PACE-Brunswick County		Elderhaus PACE-Brunswick County	1	3	0									2222 S. 17th Street		Wilmington	NC	28401		kelly.valade@elderhaus.com	kelly.valade@elderhaus.com	2000000000207301730307301730407301730507301730607301730000000000	2000000000207301730307301730407301730507301730607301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.elderhaus.com	0	0	1			0					3	0	0		www.elderhaus.com	www.elderhaus.com
H3949	009	0	2021	01	Cigna TotalCare (HMO D-SNP)	Philadelphia Area	Cigna TotalCare (HMO D-SNP)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	013	0	2021	01	Cigna Preferred Plus Medicare (HMO)	Philadelphia Area	Cigna Preferred Plus Medicare (HMO)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	016	0	2021	01	Cigna Traditions Medicare (HMO I-SNP)	Philadelphia Area	Cigna Traditions Medicare (HMO I-SNP)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	1	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	024	0	2021	01	Cigna Achieve Medicare (HMO C-SNP)	Philadelphia Area	Cigna Achieve Medicare (HMO C-SNP)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	4	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	026	0	2021	01	Cigna Fundamental Medicare (HMO)	Philadelphia Area	Cigna Fundamental Medicare (HMO)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	030	0	2021	01	Cigna Preferred Medicare (HMO)	Philadelphia Area	Cigna Preferred Medicare (HMO)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	031	0	2021	01	Cigna Alliance Medicare (HMO)	Philadelphia Area	Cigna Alliance Medicare (HMO)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	032	0	2021	01	Cigna Preferred Medicare (HMO)	Southern New Jersey	Cigna Preferred Medicare (HMO)	Southern New Jersey	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	033	0	2021	01	Cigna Preferred Plus Medicare (HMO)	Southern New Jersey	Cigna Preferred Plus Medicare (HMO)	Southern New Jersey	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	034	0	2021	01	Cigna Preferred Medicare (HMO)	Central New Jersey	Cigna Preferred Medicare (HMO)	Central New Jersey	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	035	0	2021	01	Cigna Preferred Medicare (HMO)	Central Pennsylvania	Cigna Preferred Medicare (HMO)	Central Pennsylvania	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	036	0	2021	01	Cigna TotalCare (HMO D-SNP)	Central Pennsylvania	Cigna TotalCare (HMO D-SNP)	Central Pennsylvania	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3949	804	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide PA	Cigna Preferred Medicare (HMO)	Statewide PA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H3952	008	0	2021	01	Keystone 65 Preferred Medical Only (HMO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	020	0	2021	01	Keystone 65 Preferred Rx (HMO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	044	0	2021	01	Keystone 65 Preferred Medical Only (HMO)	Chester, Delaware, Montgomery Counties		Chester, Delaware, Montgomery Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	045	0	2021	01	Keystone 65 Preferred Rx (HMO)	Chester, Delaware, Montgomery Counties		Chester, Delaware, Montgomery Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	048	0	2021	01	Keystone 65 Select Medical Only (HMO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	049	0	2021	01	Keystone 65 Select Rx (HMO)	Bucks, Philadelphia Counties		Bucks, Philadelphia Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	050	0	2021	01	Keystone 65 Select Medical Only (HMO)	Chester, Delaware, Montgomery Counties		Chester, Delaware, Montgomery Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	051	0	2021	01	Keystone 65 Select Rx (HMO)	Chester, Delaware, Montgomery Counties		Chester, Delaware, Montgomery Counties	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	053	0	2021	02	Keystone 65 Focus Rx (HMO-POS)	Philadelphia, Bucks		Philadelphia, Bucks	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	054	0	2021	02	Keystone 65 Focus Rx (HMO-POS)	Chester, Delaware, Montgomery		Chester, Delaware, Montgomery	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	055	0	2021	01	Keystone 65 Basic Rx (HMO)	Philadelphia, Bucks		Philadelphia, Bucks	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	056	0	2021	01	Keystone 65 Basic Rx (HMO)	Chester, Delaware, Montgomery		Chester, Delaware, Montgomery	1	0	0	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	802	0	2021	01	Keystone 65 Group Medical Only (HMO)	Bucks,Chester,Delaware,Montgomery,Philadelphia Cty		Bucks,Chester,Delaware,Montgomery,Philadelphia Cty	1	3	1	P.O. Box 13713		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3952	804	0	2021	01	Keystone 65 Group Rx (HMO)	Bucks,Chester,Delaware,Montgomery,Philadelphia Cty		Bucks,Chester,Delaware,Montgomery,Philadelphia Cty	1	3	1	P.O. Box 13713		Philadelphia	PA	19101				P.O. Box 13713		Philadelphia	PA	19101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ibxmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.ibxmedicare.com	www.ibxmedicare.com	www.ibxmedicare.com
H3954	097	0	2021	01	Geisinger Gold Secure Rx (HMO D-SNP)	Pennsylvania		Pennsylvania	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	156	13	2021	01	Geisinger Gold Classic Advantage (HMO)	Pennsylvania		Midstate	1	0	0	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	156	14	2021	01	Geisinger Gold Classic Advantage (HMO)	Pennsylvania		Central	1	0	0	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	156	15	2021	01	Geisinger Gold Classic Advantage (HMO)	Pennsylvania		Bucks, Carbon, Lehigh, Monroe, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	156	16	2021	01	Geisinger Gold Classic Advantage (HMO)	Pennsylvania		Midwest	1	0	0	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	156	17	2021	01	Geisinger Gold Classic Advantage (HMO)	Pennsylvania		Midsouth	1	0	0	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	156	18	2021	01	Geisinger Gold Classic Advantage (HMO)	Pennsylvania		Adams, Franklin, York	1	0	0	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	157	13	2021	01	Geisinger Gold Classic Advantage Rx (HMO)	Pennsylvania		Midstate	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	157	14	2021	01	Geisinger Gold Classic Advantage Rx (HMO)	Pennsylvania		Central	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	157	15	2021	01	Geisinger Gold Classic Advantage Rx (HMO)	Pennsylvania		Bucks, Carbon, Lehigh, Monroe, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	157	16	2021	01	Geisinger Gold Classic Advantage Rx (HMO)	Pennsylvania		Midwest	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	157	17	2021	01	Geisinger Gold Classic Advantage Rx (HMO)	Pennsylvania		Midsouth	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	157	18	2021	01	Geisinger Gold Classic Advantage Rx (HMO)	Pennsylvania		Adams, Franklin, York	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	158	13	2021	01	Geisinger Gold Classic Complete Rx (HMO)	Pennsylvania		Midstate	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	158	14	2021	01	Geisinger Gold Classic Complete Rx (HMO)	Pennsylvania		Central	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	158	15	2021	01	Geisinger Gold Classic Complete Rx (HMO)	Pennsylvania		Bucks, Carbon, Lehigh, Monroe, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	158	16	2021	01	Geisinger Gold Classic Complete Rx (HMO)	Pennsylvania		Midwest	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	158	17	2021	01	Geisinger Gold Classic Complete Rx (HMO)	Pennsylvania		Midsouth	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	158	18	2021	01	Geisinger Gold Classic Complete Rx (HMO)	Pennsylvania		Adams, Franklin, York	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	159	13	2021	01	Geisinger Gold Classic Essential Rx (HMO)	Pennsylvania		Midstate	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	159	14	2021	01	Geisinger Gold Classic Essential Rx (HMO)	Pennsylvania		Central	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	159	15	2021	01	Geisinger Gold Classic Essential Rx (HMO)	Pennsylvania		Bucks, Carbon, Lehigh, Monroe, Northampton	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	159	16	2021	01	Geisinger Gold Classic Essential Rx (HMO)	Pennsylvania		Midwest	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	159	17	2021	01	Geisinger Gold Classic Essential Rx (HMO)	Pennsylvania		Midsouth	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	159	18	2021	01	Geisinger Gold Classic Essential Rx (HMO)	Pennsylvania		Adams, Franklin, York	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	160	0	2021	01	Geisinger Gold Classic 360 Rx (HMO)	Pennsylvania		Pennsylvania	1	0	0	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	801	0	2021	01	Geisinger Gold Classic (Employer Group) (HMO)	Pennsylvania		Pennsylvania	1	3	1	100 North Academy Avenue		Danville	PA	17822												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.geisingergold.com	https://www.thehealthplan.com/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger
H3954	802	0	2021	01	Geisinger Gold Classic Rx (Employer Group) (HMO)	Pennsylvania		Pennsylvania	1	3	1	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3954	805	0	2021	01	Geisinger Gold Classic Rx EGWP New Jersey (HMO)	Monmouth & Ocean Counties, NJ		Monmouth & Ocean Counties, NJ	1	3	1	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H3957	031	0	2021	02	Security Blue HMO-POS ValueRx (HMO-POS)	Southwestern PA		Southwestern PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	039	0	2021	01	Community Blue Medicare HMO Prestige (HMO)	Western PA		Western PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	042	1	2021	01	Community Blue Medicare HMO Signature (HMO)	North Central PA		Lehigh Valley	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	042	2	2021	01	Community Blue Medicare HMO Signature (HMO)	North Central PA		South Central PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	042	4	2021	01	Community Blue Medicare HMO Signature (HMO)	North Central PA		North Central PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	042	5	2021	01	Community Blue Medicare HMO Signature (HMO)	North Central PA		Lancaster PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	043	1	2021	02	Security Blue HMO-POS Basic (HMO-POS)	Western PA		Southwest PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	2	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	043	2	2021	02	Security Blue HMO-POS Basic (HMO-POS)	Western PA		West Central PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	2	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	043	3	2021	02	Security Blue HMO-POS Basic (HMO-POS)	Western PA		Potter PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	2	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	044	1	2021	02	Security Blue HMO-POS ValueRx (HMO-POS)	Western PA		West Central PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	044	2	2021	02	Security Blue HMO-POS ValueRx (HMO-POS)	Western PA		Potter PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	045	1	2021	02	Security Blue HMO-POS Standard (HMO-POS)	Western PA		Southwest PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	045	2	2021	02	Security Blue HMO-POS Standard (HMO-POS)	Western PA		West Central PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	045	3	2021	02	Security Blue HMO-POS Standard (HMO-POS)	Western PA		Potter PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	046	1	2021	02	Security Blue HMO-POS Deluxe (HMO-POS)	Western PA		Southwest PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	046	2	2021	02	Security Blue HMO-POS Deluxe (HMO-POS)	Western PA		West Central PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	046	3	2021	02	Security Blue HMO-POS Deluxe (HMO-POS)	Western PA		Potter PA	1	0	0	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	047	1	2021	01	Community Blue Medicare HMO Signature (HMO)	Western PA		Southwest PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	047	2	2021	01	Community Blue Medicare HMO Signature (HMO)	Western PA		West Central PA	1	0	0	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	805	0	2021	01	Security Blue HMO MA Calendar (HMO)	Western PA		Western PA	1	3	1	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	2	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	806	0	2021	01	Security Blue HMO MA-PD Calendar (HMO)	Western PA		Western PA	1	3	1	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	808	0	2021	01	Security Blue HMO MA-PD Non-Calendar (HMO)	Western PA		Western PA	1	3	1	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	810	0	2021	01	Community Blue Medicare HMO MA Calendar (HMO)	Pennsylvania (Western and North Central)		Pennsylvania (Western and North Central)	1	3	1	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	811	0	2021	01	Community Blue Medicare HMO MA-PD Calendar (HMO)	Pennsylvania (Western and North Central)		Pennsylvania (Western and North Central)	1	3	1	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	812	0	2021	01	Community Blue Medicare HMO MA-PD Non-Calendar (HMO)	Pennsylvania (Western and North Central)		Pennsylvania (Western and North Central)	1	3	1	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Community Blue Medicare	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	813	0	2021	02	Security Blue HMO-POS MA Calendar (HMO-POS)	Western PA		Western PA	1	3	1	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	2	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	814	0	2021	02	Security Blue HMO-POS MA-PD Calendar (HMO-POS)	Western PA		Western PA	1	3	1	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3957	815	0	2021	02	Security Blue HMO-POS MA-PD Non-Calendar (HMO-POS)	Western PA		Western PA	1	3	1	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	Security Blue	P.O. Box 1068	Pittsburgh	PA	15230		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	medicare.highmark.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H3959	001	0	2021	01	Aetna Medicare Advantra Gold (HMO)	Allegheny County		Allegheny County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	002	0	2021	01	Aetna Medicare Advantra Gold (HMO)	Western Pennsylvania		Western Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	010	0	2021	01	Aetna Medicare Advantra Silver (HMO)	Allegheny County		Allegheny County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	011	0	2021	01	Aetna Medicare Advantra Silver (HMO)	Western Pennsylvania		Western Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	032	0	2021	01	Aetna Medicare Advantra Premier (HMO)	Northwestern Pennsylvania		Northwestern Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	033	0	2021	01	Aetna Medicare Advantra Premier (HMO)	Southeastern Pennsylvania		Southeastern Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	035	0	2021	01	Aetna Medicare Advantra Cares (HMO D-SNP)	Southeastern Pennsylvania		Southeastern Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	036	0	2021	01	Aetna Medicare Advantra Cares (HMO D-SNP)	Central and Western Pennsylvania		Central and Western Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	037	0	2021	01	Aetna Medicare Advantra Gold (HMO)	Northeastern Pennsylvania		Northeastern Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	039	0	2021	01	Aetna Medicare Advantra Premier (HMO)	Central Pennsylvania		Central Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	041	0	2021	01	Aetna Medicare Advantra Eagle (HMO)	Central and Western Pennsylvania		Central and Western Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	045	0	2021	01	Aetna Medicare PennHighlands Prime (HMO)	Clearfield, Elk and Jefferson Counties		Clearfield, Elk and Jefferson Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	046	0	2021	01	Aetna Medicare Advantra Washington Prime (HMO)	Greene and Washington Counties		Greene and Washington Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	047	0	2021	01	Aetna Medicare Advantra Butler Prime (HMO)	Butler County		Butler County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	049	0	2021	01	Aetna Medicare Advantra Excela Prime (HMO)	Westmoreland County		Westmoreland County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	051	0	2021	01	Aetna Medicare Beaver Valley Prime (HMO)	Beaver County		Beaver County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	052	0	2021	01	Aetna Medicare Advantra Value (HMO)	Southeastern Pennsylvania		Southeastern Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	053	0	2021	01	Aetna Medicare Advantra Philly Prime (HMO)	Philadelphia Metro Area		Philadelphia Metro Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	055	0	2021	01	Aetna Medicare Advantra Value (HMO)	Kent, Sussex, New Castle counties		Kent, Sussex, New Castle counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	803	0	2021	01	Aetna Medicare Plan (HMO)	Pennsylvania		Pennsylvania	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3959	804	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Pennsylvania		Pennsylvania	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H3962	001	0	2021	01	BlueJourney Premier (HMO)	21 Counties in Central PA		21 Counties in Central PA	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	004	0	2021	01	BlueJourney Value (HMO)	21 Counties in Central PA		21 Counties in Central PA	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	007	0	2021	01	BlueJourney Essential (HMO)	21 Counties in Central PA		21 Counties in Central PA	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	801	0	2021	01	BlueJourney Group HMO Silver Rx (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	802	0	2021	01	BlueJourney Group HMO Without Rx (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	2	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	803	0	2021	01	BlueJourney Group HMO Bronze Rx FY (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	813	0	2021	01	BlueJourney Group HMO Gold Rx (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	814	0	2021	01	BlueJourney Group HMO Platinum Rx (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	815	0	2021	01	BlueJourney Group HMO Bronze Rx (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	816	0	2021	01	BlueJourney Group HMO Platinum Rx FY (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	817	0	2021	01	BlueJourney Group HMO Silver Rx FY (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3962	818	0	2021	01	BlueJourney Group HMO Gold Rx FY (HMO)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2500 Elmerton Avenue		Harrisburg	PA	17177		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalbluemedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.capitalbluemedicare.com	www.capitalbluemedicare.com	www.capitalbluemedicare.com
H3975	001	0	2021	04	WellCare Premier (PPO)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H3979	001	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	Oklahoma City Metro Area		Oklahoma City Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueok.com/mapd	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getblueok.com/mapd/providers	www.getblueok.com/mapd/pharmacies	www.getblueok.com/mapd/druglist
H3979	801	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getblueok.com/mapd	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	getblueok.com/mapd/providers	www.getblueok.com/mapd/pharmacies	www.getblueok.com/mapd/druglist
H3979	803	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getblueok.com/mapd	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	getblueok.com/mapd/providers	www.getblueok.com/mapd/pharmacies	www.getblueok.com/mapd/druglist
H3979	805	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getblueok.com/mapd	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	getblueok.com/mapd/providers	www.getblueok.com/mapd/pharmacies	www.getblueok.com/mapd/druglist
H3991	001	0	2021	20	Cherry Blossom PACE - Dual Eligible (PACE)	Northern Virginia		Northern Virginia	1	3	0									1901 N Beauregard St. Ste 110		Alexandria	VA	22311				2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.	0	WWW.cherryblossompace.com	0	0	1			0					3	0	0		www.carekinesses.com	www.cherryblossompace.com
H3991	002	0	2021	20	Cherry Blossom PACE - Medicare Only (PACE)	Northern Virginia		Northern Virginia	1	3	0									1901 N Beauregard St. Ste 110		Alexandria	VA	22311				2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.	0	WWW.cherryblossompace.com	0	0	1			0					3	0	0		www.carekinesses.com	www.cherryblossompace.com
H4003	009	0	2021	01	MMM Supremo (HMO C-SNP)	Puerto Rico	MMM Supremo (HMO C-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	4	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	017	0	2021	01	MMM Diamante Platino (HMO D-SNP)	Puerto Rico	MMM Diamante Platino (HMO D-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	019	0	2021	02	MMM Unico (HMO-POS)	Puerto Rico	MMM Unico (HMO-POS)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	034	0	2021	02	MMM Elite (HMO-POS)	Puerto Rico	MMM Elite (HMO-POS)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	044	0	2021	02	MMM Extra (HMO-POS)	Puerto Rico	MMM Extra (HMO-POS)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	047	0	2021	01	MMM Valor Platino (HMO D-SNP)	Puerto Rico	MMM Valor Platino (HMO D-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	049	0	2021	01	MMM Grande Platino (HMO D-SNP)	Puerto Rico	MMM Grande Platino (HMO D-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1000000000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	050	0	2021	01	MMM Conectado Platino (HMO D-SNP)	Puerto Rico	MMM Conectado Platino (HMO D-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	051	0	2021	02	MMM Dinamico (HMO-POS)	Puerto Rico	MMM Dinamico (HMO-POS)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	806	0	2021	02	MMM Group $0 Calendar (HMO-POS)	Puerto Rico	MMM Group $0 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	807	0	2021	02	MMM Group $25 Calendar (HMO-POS)	Puerto Rico	MMM Group $25 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	820	0	2021	02	MMM Group $50 Calendar (HMO-POS)	Puerto Rico	MMM Group $50 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	821	0	2021	02	MMM Group $100 Calendar (HMO-POS)	Puerto Rico	MMM Group $100 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H4003	822	0	2021	02	MMM Group $0 Non-Calendar (HMO-POS)	Puerto Rico	MMM Group $0 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H4003	823	0	2021	02	MMM Group $25 Non-Calendar (HMO-POS)	Puerto Rico	MMM Group $25 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H4003	824	0	2021	02	MMM Group $50 Non-Calendar (HMO-POS)	Puerto Rico	MMM Group $50 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H4003	825	0	2021	02	MMM Group $100 Non-Calendar (HMO-POS)	Puerto Rico	MMM Group $100 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H4003	826	0	2021	02	MMM Group $144.60 Calendar (HMO-POS)	Puerto Rico	MMM Group $144.60 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H4003	827	0	2021	02	MMM Group $144.60 Non-Calendar (HMO-POS)	Puerto Rico	MMM Group $144.60 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H4004	048	0	2021	01	PMC Premier Platino (HMO D-SNP)	Puerto Rico	PMC Premier Platino (HMO D-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	056	0	2021	02	PMC Max (HMO-POS)	Puerto Rico	PMC Max (HMO-POS)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	061	0	2021	01	MMM Relax Platino (HMO D-SNP)	Puerto Rico	MMM Relax Platino (HMO D-SNP)	Puerto Rico	1	0	0	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	817	0	2021	02	PMC Group $0 Calendar (HMO-POS)	Puerto Rico	PMC Group $0 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	818	0	2021	02	PMC Group $25 Calendar (HMO-POS)	Puerto Rico	PMC Group $25 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	819	0	2021	02	PMC Group $50 Calendar (HMO-POS)	Puerto Rico	PMC Group $50 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	820	0	2021	02	PMC Group $100 Calendar (HMO-POS)	Puerto Rico	PMC Group $100 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	822	0	2021	02	PMC Group $0 Non-Calendar (HMO-POS)	Puerto Rico	PMC Group $0 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	823	0	2021	02	PMC Group $25 Non-Calendar (HMO-POS)	Puerto Rico	PMC Group $25 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	824	0	2021	02	PMC Group $50 Non-Calendar (HMO-POS)	Puerto Rico	PMC Group $50 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	825	0	2021	02	PMC Group $100 Non-Calendar (HMO-POS)	Puerto Rico	PMC Group $100 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	826	0	2021	02	PMC Group $144.60 Calendar (HMO-POS)	Puerto Rico	PMC Group $144.60 Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4004	827	0	2021	02	PMC Group $144.60 Non-Calendar (HMO-POS)	Puerto Rico	PMC Group $144.60 Non-Calendar (HMO-POS)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.mmmpr.com	www.mmmpr.com	www.mmmpr.com
H4005	001	0	2021	04	Óptimo (PPO)	Puerto Rico	Óptimo (PPO)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com									1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4005	004	0	2021	04	Óptimo Plus (PPO)	Puerto Rico	Óptimo Plus (PPO)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4005	801	0	2021	04	Óptimo (PPO)	Puerto Rico	Óptimo (PPO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com									1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4005	802	0	2021	04	Óptimo Plus A (PPO)	Puerto Rico	Óptimo Plus A (PPO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4005	804	0	2021	04	Óptimo Plus B (PPO)	Puerto Rico	Óptimo Plus B (PPO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4005	807	0	2021	04	Óptimo Plus C (PPO)	Puerto Rico	Óptimo Plus C (PPO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4005	808	0	2021	04	Óptimo Plus D (PPO)	Puerto Rico	Óptimo Plus D (PPO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H4007	012	0	2021	01	Humana Gold Plus H4007-012 (HMO)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000707001800	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	013	0	2021	01	Humana Gold Plus H4007-013 (HMO)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000707001800	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	016	0	2021	01	Humana Gold Plus SNP-DE H4007-016 (HMO D-SNP)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000707001800	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	018	0	2021	01	Humana Gold Plus SNP-DE H4007-018 (HMO D-SNP)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	019	0	2021	01	Humana Gold Plus SNP-DE H4007-019 (HMO D-SNP)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	020	0	2021	01	Humana Gold Plus H4007-020 (HMO)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	021	0	2021	01	Humana Gold Plus H4007-021 (HMO)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	022	0	2021	01	Humana Gold Plus SNP-DE H4007-022 (HMO D-SNP)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	023	0	2021	01	Humana Gold Plus SNP-DE H4007-023 (HMO D-SNP)	Puerto Rico Island Wide		Puerto Rico Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	801	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	802	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	811	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	812	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	813	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	814	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	815	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4007	816	0	2021	01	Humana Medicare Employer (HMO)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4036	008	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	009	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	010	1	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	010	2	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	016	0	2021	04	Anthem MediBlue Access Core (PPO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com										9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	017	0	2021	04	Anthem MediBlue Access Plus (PPO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $40.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $40.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	020	0	2021	04	Anthem MediBlue Access Plus (PPO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4036	801	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	802	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	803	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	805	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	806	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	807	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	808	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	809	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	810	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	811	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	812	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	813	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4036	814	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												3000000000208002100308002100408002100508002100608002100000000000	3000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4053	001	0	2021	20	Prisma Health PACE-Upstate - Dual Eligible (PACE)	Anderson, Greenville and Pickens counties		Anderson, Greenville and Pickens counties	1	3	0									32 Centennial Way		Greenville	SC	29605				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.ghs.org/healthcareservices/seniorcare/	0	0	1			0					3	0	0	https://www.ghs.org/providers/ohmar-win/	https://www.ghs.org/healthcareservices/upstate-pharmacy/	N/A
H4053	002	0	2021	20	Prisma Health PACE-Upstate - Medicare Only (PACE)	Anderson, Greenville and Pickens counties		Anderson, Greenville and Pickens counties	1	3	0									32 Centennial Way		Greenville	SC	29605				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.ghs.org/healthcareservices/seniorcare/	0	0	1			0					3	0	0	https://www.ghs.org/providers/ohmar-win/	https://www.ghs.org/healthcareservices/upstate-pharmacy/	N/A
H4074	001	0	2021	20	Mercy LIFE of Alabama (PACE)	Mercy LIFE of Alabama Baldwin and Mobile counties		Mercy LIFE of Alabama Baldwin and Mobile counties	1	3	0									2900 Springhill Avenue		Mobile	AL	36607		gemmac@mercylifeal.com	gemmac@mercylifeal.com	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	mercylifeal.com	0	0	1			0					3	0	0	mercylifeal.com	pharmastarpbm.com	www.mercylifeal.com
H4074	002	0	2021	20	Mercy LIFE of Alabama (PACE)	Mercy LIFE of Alabama Baldwin and Mobile counties		Mercy LIFE of Alabama Baldwin and Mobile counties	1	3	0									2900 Springhill Avenue		Mobile	AL	36607		gemmac@mercylifeal.com	gemmac@mercylifeal.com	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	mercylifeal.com	0	0	1			0					3	0	0	mercylifeal.com	pharmastarpbm.com	www.mercylifeal.com
H4091	001	0	2021	04	Simpra Advantage (PPO I-SNP)	Alabama statewide		Alabama statewide	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.simpra.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.simpra.com	www.simpra.com	www.simpra.com
H4091	002	0	2021	04	Simpra Advantage (PPO D-SNP)	Alabama statewide		Alabama statewide	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.simpra.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.simpra.com	www.simpra.com	www.simpra.com
H4091	003	0	2021	04	Simpra Advantage Premier (PPO I-SNP)	Alabama statewide		Alabama statewide	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.simpra.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	0	www.simpra.com	www.simpra.com	www.simpra.com
H4093	001	0	2021	01	Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)	PA East & West Borders		PA East & West Borders	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H4093	004	0	2021	01	Provider Partners Pennsylvania Community Plan (HMO I-SNP)	PA East & West Borders		PA East & West Borders	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H4094	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Montgomery County		Montgomery County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4105	001	0	2021	20	PACE Organization of Rhode Island (PACE)	Most of Rhode Island		Most of Rhode Island	1	3	0									225 Chapman Street		Providence	RI	02905		outreachdirector@pace-ri.org	outreachdirector@pace-ri.org	2000000000207001700307001700407001700507001700607001700707001400	2000000000207001700307001700407001700507001700607001700707001400	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pace-ri.org	0	0	1			0					3	0	0		www.pace-ri.org	www.pace-ri.org
H4105	002	0	2021	20	PACE Organization of Rhode Island (PACE)	Most of Rhode Island		Most of Rhode Island	1	3	0									225 Chapman Street		Providence	RI	02905		outreachdirector@pace-ri.org	outreachdirector@pace-ri.org	2000000000207001700307001700407001700507001700607001700707001400	2000000000207001700307001700407001700507001700607001700707001400	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pace-ri.org	0	0	1			0					3	0	0		www.pace-ri.org	www.pace-ri.org
H4118	001	0	2021	20	Huron Valley PACE - Dual Eligible (PACE)	Wash Co, Parts of Mon, Oak, Wayne & Livingston Co		Wash Co, Parts of Mon, Oak, Wayne & Livingston Co	1	3	0									2940 Ellsworth Road		Ypsilanti	MI	48197		lmann-shanahan@hvpace.org	jdukes@hvpace.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.huronvalleypace.org	0	0	1			0					3	0	0		http://www.hometownpharmacy.com/	http://huronvalleypace.org/
H4118	002	0	2021	20	Huron Valley PACE - Medicare Only (PACE)	Wash Co, Parts of Mon, Oak, Wayne & Livingston Co		Wash Co, Parts of Mon, Oak, Wayne & Livingston Co	1	3	0									2940 Ellsworth Road		Ypsilanti	MI	48197		myoung@hvpace.org	jdukes@hvpace.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.huronvalleypace.org	0	0	1			0					3	0	0		http://www.hometownpharmacy.com/	http://huronvalleypace.org/
H4140	001	0	2021	02	DrMax (HMO-POS)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com		2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4140	002	0	2021	02	DrPlus (HMO-POS D-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com		2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4140	003	0	2021	02	DrCare (HMO-POS C-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce de Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2020 Ponce de Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4140	004	0	2021	02	DrExtra (HMO-POS C-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce de Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2020 Ponce de Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4140	005	0	2021	02	DrValue (HMO-POS)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce de Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2020 Ponce de Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4140	006	0	2021	02	DrFirst (HMO-POS)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4140	007	0	2021	02	DrChoice (HMO-POS)	Miami-Dade County		Miami-Dade County	1	0	0	2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2020 Ponce De Leon Blvd	PH 1	Coral Gables	FL	33134		meduran@doctorshcp.com	meduran@doctorshcp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.doctorshcp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.doctorshcp.com	www.doctorshcp.com	www.doctorshcp.com
H4141	003	0	2021	01	Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP)	Greater Georgia Area		Greater Georgia Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	015	0	2021	01	Humana Gold Plus H4141-015 (HMO)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	017	3	2021	01	Humana Gold Plus H4141-017 (HMO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	017	4	2021	01	Humana Gold Plus H4141-017 (HMO)	Select Counties in Georgia		Atlanta	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	017	5	2021	01	Humana Gold Plus H4141-017 (HMO)	Select Counties in Georgia		Macon and Albany Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	801	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Georgia		Select counties in Georgia	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	802	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Georgia		Select counties in Georgia	1	3	1	500 West Main Street		Louisville	KY	40202												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	805	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Georgia		Select counties in Georgia	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4141	806	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Georgia		Select counties in Georgia	1	3	1	500 West Main Street		Louisville	KY	40202												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4142	001	0	2021	20	Cherokee Elder Care (PACE)	Cherokee and surrounding counties		Cherokee and surrounding counties	1	3	0									1387 W 4th St.		Tahlequah	OK	74464		eldercare@cherokee.org	eldercare@cherokee.org	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://eldercare.cherokee.org	0	0	1			0					3	0	0		N/A	N/A
H4142	002	0	2021	20	Cherokee Elder Care (PACE)	Cherokee and surrounding counties		Cherokee and surrounding counties	1	3	0									1387 W 4th St.		Tahlequah	OK	74464		eldercare@cherokee.org	eldercare@cherokee.org	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://eldercare.cherokee.org	0	0	1			0					3	0	0		N/A	N/A
H4152	004	0	2021	01	BlueCHiP for Medicare Core (HMO)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903												2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	005	0	2021	01	BlueCHiP for Medicare Plus (HMO)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	007	0	2021	02	BlueCHiP for Medicare Preferred (HMO-POS)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	013	0	2021	01	BlueCHiP for Medicare Standard with Drugs (HMO)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	017	0	2021	01	BlueCHiP for Medicare Advance (HMO)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	018	0	2021	02	BlueCHiP for Medicare Extra (HMO-POS)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	020	0	2021	02	BlueCHiP for Medicare Value (HMO-POS)	State of Rhode Island		State of Rhode Island	1	0	0	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	815	0	2021	02	BlueCHiP for Medicare Group Preferred (HMO-POS)	RI, Bristol Cty MA, Partial New London Cty CT		RI, Bristol Cty MA, Partial New London Cty CT	1	3	1	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4152	817	0	2021	01	BlueCHiP for Medicare Group Plus (HMO)	RI, Bristol Cty MA, Partial New London Cty CT		RI, Bristol Cty MA, Partial New London Cty CT	1	3	1	500 Exchange Street		Providence	RI	02903				500 Exchange Street		Providence	RI	02903				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.BCBSRI.com/Medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://findadoctor.bcbsri.com/	www.BCBSRI.com/Medicare	www.BCBSRI.com/Medicare
H4172	001	0	2021	01	NHC Advantage (HMO I-SNP)	Missouri (partial) Tennessee (partial)		Missouri (partial) Tennessee (partial)	1	0	0	PO Box 5849		Glen Allen	VA	23058				PO Box 5849		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.nhcadvantageplan.com	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.nhcadvantageplan.com	www.nhcadvantageplan.com	www.nhcadvantageplan.com
H4172	002	0	2021	01	NHC Advantage Gold (HMO I-SNP)	Missouri (partial) Tennessee (partial)		Missouri (partial) Tennessee (partial)	1	0	0	PO Box 5849		Glen Allen	VA	23058				PO Box 5849		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.nhcadvantageplan.com	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.nhcadvantageplan.com	www.nhcadvantageplan.com	www.nhcadvantageplan.com
H4185	001	0	2021	20	Neighborhood Healthcare PACE Dual Eligible (PACE)	Riverside and San Bernardino Counties		Riverside and San Bernardino Counties	1	3	0									4371 Latham Street		Riverside	CA	92501		paceenrollment@nhcare.org	paceenrollment@nhcare.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nhcarepace.org	0	0	1			0					3	0	0	www.nhcarepace.org	www.nhcarepace.org	https://www.Nhcarepace.org
H4185	002	0	2021	20	Neighborhood Healthcare PACE Medicare Only (PACE)	Riverside and San Bernardino Counties		Riverside and San Bernardino Counties	1	3	0									4371 Latham Street		Riverside	CA	92501		nicole.holmes@nhcare.org	nicole.holmes@nhcare.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nhcarepace.org	0	0	1			0					3	0	0	www.nhcarepace.org	www.nhcarepace.org	https://www.Nhcarepace.org
H4198	001	0	2021	01	Advantage Choice (HMO)	Counties CG, CK, MC, MU, NO, OS, TU, WG, WS		Counties CG, CK, MC, MU, NO, OS, TU, WG, WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com	www.ccokadvantage.com/2021/AMP/pharmacy-and-Rx-info.asp	www.medicareplanrx.com/jccf/ccok_amp_formulary_21.html
H4198	003	0	2021	01	Advantage Premier (HMO)	Counties CG, CK, MC, MU, NO, OS, TU, WG, WS		Counties CG, CK, MC, MU, NO, OS, TU, WG, WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com	www.ccokadvantage.com/2021/AMP/Pharmacy-and-Rx-Info.asp	www.medicareplanrx.com/jccf/ccok_amp_formulary_21.html
H4198	005	0	2021	01	Advantage Choice Plus (HMO)	Counties CG, CK, MC, MU, NO, OS, TU, WG, WS		Counties CG, CK, MC, MU, NO, OS, TU, WG, WS	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.ccokadvantage.com	www.ccokadvantage.com/2021/AMP/Pharmacy-and-Rx-Info.asp	www.medicareplanrx.com/jccf/ccok_amp_formulary_21.html
H4203	001	0	2021	20	Prisma Health PACE-Midlands - Dual Eligible (PACE)	Richland and  Lexington Counties		Richland and  Lexington Counties	1	3	0									1308 Laurel Street		Columbia	SC	29201		shirley.gregg@palmettohealth.org	allison.ashley@prismahealth.org	2107001830207001830307001830407001830507001830607001830707001830	2107001830207001830307001830407001830507001830607001830707001830	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Palmettohealth.org	0	0	1			0					3	0	0		N/A	n/a
H4203	002	0	2021	20	Prisma Health PACE-Midlands - Medicare Only (PACE)	Richland and Lexington Counties		Richland and Lexington Counties	1	3	0									1308 Laurel Street		Columbia	SC	29201		shirley.gregg@palmettohealth.org	allison.ashley@prismahealth.org	2107001800207001800307001800407001800507001800607001800707001800	2107001800207001800307001800407001800507001800607001800707001800	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Palmettohealth.org	0	0	1			0					3	0	0		N/A	n/a
H4213	016	1	2021	09	BlueMedicare Value (PFFS)	State of Arkansas		Northern, Western and South Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H4213	016	3	2021	09	BlueMedicare Value (PFFS)	State of Arkansas		Northwest, Western and Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H4213	016	4	2021	09	BlueMedicare Value (PFFS)	State of Arkansas		East Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H4213	017	1	2021	09	BlueMedicare Preferred (PFFS)	State of Arkansas		Northern, Western and South Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H4213	017	5	2021	09	BlueMedicare Preferred (PFFS)	State of Arkansas		Northwest, Western and Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H4213	017	6	2021	09	BlueMedicare Preferred (PFFS)	State of Arkansas		East Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H4227	001	0	2021	01	Keystone First VIP Choice (HMO D-SNP)	Southeastern Pennsylvania		Southeastern Pennsylvania	1	0	0	200 Stevens Drive		Philadelphia	PA	19113				200 Stevens Drive		Philadelphia	PA	19113				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.keystonefirstvipchoice.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.keystonefirstvipchoice.com	www.keystonefirstvipchoice.com	www.keystonefirstvipchoice.com
H4227	002	0	2021	01	AmeriHealth Caritas VIP Care (HMO D-SNP)	Northeast, Central and Western Pennsylvania		Northeast, Central and Western Pennsylvania	1	0	0	200 Stevens Drive		Philadelphia	PA	19113				200 Stevens Drive		Philadelphia	PA	19113				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.amerihealthcaritasvipcare.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.amerihealthcaritasvipcare.com	www.amerihealthcaritasvipcare.com	www.amerihealthcaritasvipcare.com
H4232	001	0	2021	01	American Health Advantage of Utah (HMO I-SNP)	North and Central Utah		North and Central Utah	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	ut.amhealthplans.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ut.amhealthplans.com	ut.amhealthplans.com	ut.amhealthplans.com
H4235	001	0	2021	20	Senior Total Life Care Dual (PACE)	Gaston County and Parts of Cleveland and Lincoln		Gaston County and Parts of Cleveland and Lincoln	1	3	0									1875 Remount Rd		Gastonia	NC	28054		ckenzig@seniorTLC.org	ckenzig@seniorTLC.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorTLC.org	0	0	1			0					3	0	0	www.seniortlc.org	n/a	n/a
H4235	002	0	2021	20	Senior Total Life Care Medicare (PACE)	Gaston, Lincoln and Cleveland Counties in NC		Gaston, Lincoln and Cleveland Counties in NC	1	3	0									1875 Remount Rd		Gastonia	NC	28054		ckenzig@seniorTLC.org	ckenzig@seniorTLC.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorTLC.org	0	0	1			0					3	0	0	www.seniortlc.org	n/a	n/a
H4256	001	0	2021	20	PACE North, Inc (PACE)	Grand Traverse, Benz, Leel,Wexf, Kalk, Antr, Mani		Grand Traverse, Benz, Leel,Wexf, Kalk, Antr, Mani	1	3	0									2325 N Garfield RD		Traverse City	MI	49686				2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacenorth.org	0	0	1			0					3	0	0		KalamazooLTCPharmacy.com	N/A
H4256	002	0	2021	20	PACE North, Inc (PACE)	Grand Traverse, Benz, Leel,Wexf, Kalk, Antr, Mani		Grand Traverse, Benz, Leel,Wexf, Kalk, Antr, Mani	1	3	0									2325 N Garfield RD		Traverse City	MI	49686				2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacenorth.org	0	0	1			0					3	0	0		KalamazooLTCPharmacy.com	N/A
H4279	001	0	2021	01	UPMC for Life Complete Care (HMO D-SNP)	Western Pennsylvania		Western Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.upmchealthplan.com/snp	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	http://www.upmchealthplan.com/snp	www.upmchealthplan.com/medicare/documents-and-forms	www.upmchealthplan.com/medicare/documents-and-forms
H4279	004	0	2021	01	UPMC for Life Complete Care (HMO D-SNP)	Eastern Pennsylvania		Eastern Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/snp	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	http://www.upmchealthplan.com/snp	http://www.upmchealthplan.com/medicare/documents-and-forms	http://www.upmchealthplan.com/medicare/documents-and-forms
H4304	001	0	2021	04	Advantage U Signature (PPO)	Davis, Salt Lake, Tooele, Utah and Weber Counties	Advantage U Signature (PPO)	Davis, Salt Lake, Tooele, Utah and Weber Counties	1	0	0	PO Box 3117		Scranton	PA	18505				PO Box 3117		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AdvantageUMedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com
H4304	801	0	2021	04	Advantage U CY EWGP (PPO)	Davis, Salt Lake, Tooele, Utah and Weber Counties	Advantage U CY EWGP (PPO)	Davis, Salt Lake, Tooele, Utah and Weber Counties	1	3	1	PO Box 3117		Scranton	PA	18505				PO Box 3117		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AdvantageUMedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com
H4304	802	0	2021	04	Advantage U BY EWGP (PPO)	Davis, Salt Lake, Tooele, Utah and Davis Counties	Advantage U BY EWGP (PPO)	Davis, Salt Lake, Tooele, Utah and Davis Counties	1	3	1	PO Box 3117		Scranton	PA	18505				PO Box 3117		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AdvantageUMedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com
H4304	803	0	2021	04	Advantage U EWGP MA ONLY (PPO)	Davis, Salt Lake, Tooele, Utah and Weber Counties	Advantage U EWGP MA ONLY (PPO)	Davis, Salt Lake, Tooele, Utah and Weber Counties	1	3	1	PO Box 3117		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AdvantageUMedicare.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com	www.AdvantageUMedicare.com
H4305	001	0	2021	20	Total Life Healthcare Dual (PACE)	Counties: Craighead Cross Greene Law MS Poin Rand		Counties: Craighead Cross Greene Law MS Poin Rand	1	3	0									225 East Jackson #92	712 E. Washington Avenue	Jonesboro	AR	72401		tcombs@sbrmc.org	tcombs@sbrmc.org	3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.stbernards.info/	0	0	1			0					3	0	0		n/a	n/a
H4305	002	0	2021	20	Total Life Healthcare Medicare only (PACE)	Counties:Craighead Cross Greene Law MS Poin Rand		Counties:Craighead Cross Greene Law MS Poin Rand	1	3	0									225 East Jackson #92	712 E Washington	Jonesboro	AR	72401		tcombs@sbrmc.org	tcombs@sbrmc.org	3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.stbernards.info/	0	0	1			0					3	0	0		n/a	n/a
H4326	001	0	2021	20	PACE at Home - dual (PACE)	Catawba Co. and Surrounding Select Zip Codes		Catawba Co. and Surrounding Select Zip Codes	1	3	0									1915 Fairgrove Church Road SE		Newton	NC	28658				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pace-at-home.org	0	0	1			0					3	0	0		www.carekinesis.com	www.pace-at-home.org
H4326	002	0	2021	20	PACE at Home - medicare only (PACE)	Catawba Co. and Surrounding Select Zip Codes		Catawba Co. and Surrounding Select Zip Codes	1	3	0									1915 Fairgrove Church Road SE		Newton	NC	28658				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pace-at-home.org	0	0	1			0					3	0	0		www.carekinesis.com	www.pace-at-home.org
H4343	001	0	2021	01	Ascension Complete St. Vincent's Reward (HMO)	Birmingham & Surrounding Counties in Alabama		Birmingham & Surrounding Counties in Alabama	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $390.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $390.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-formulary
H4343	002	0	2021	01	Ascension Complete Providence Reward (HMO)	Mobile area in Alabama		Mobile area in Alabama	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $390.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $390.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-formulary
H4343	003	0	2021	01	Ascension Complete St. Vincent's Secure (HMO)	Birmingham surrounding counties in Alabama		Birmingham surrounding counties in Alabama	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-formulary
H4343	004	0	2021	01	Ascension Complete Providence Secure (HMO)	Mobile area in Alabama		Mobile area in Alabama	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-findadoctor	ascensioncomplete.com/al-formulary
H4346	001	0	2021	01	Anthem MediBlue Value Plus (HMO)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	005	0	2021	01	Anthem MediBlue Lung Care (HMO C-SNP)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	006	0	2021	01	Anthem MediBlue Diabetes Care (HMO C-SNP)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	008	0	2021	01	Anthem MediBlue Heart Care (HMO C-SNP)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	009	0	2021	01	Anthem MediBlue StartSmart Plus (HMO)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	010	0	2021	01	Anthem MediBlue Care On Site (HMO I-SNP)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	011	0	2021	01	Anthem MediBlue Connect Plus (HMO)	Clark County		Clark County	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	012	0	2021	01	Anthem MediBlue Plus (HMO)	Denver Metro Area		Denver Metro Area	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	013	0	2021	01	Anthem MediBlue Plus (HMO)	El Paso, Larimer, Mesa, Pueblo, Weld, Teller		El Paso, Larimer, Mesa, Pueblo, Weld, Teller	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	014	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Greater Denver Area		Greater Denver Area	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	017	0	2021	01	Anthem MediBlue Plus (HMO)	Clark County		Clark County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	018	0	2021	01	Anthem MediBlue Coordination Plus (HMO)	Clark and Washoe Counties		Clark and Washoe Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	019	0	2021	01	Anthem MediBlue Plus (HMO)	Washoe County		Washoe County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	022	0	2021	01	Anthem MediBlue Diabetes Care (HMO C-SNP)	Denver Metro Area		Denver Metro Area	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	4	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	023	0	2021	01	Anthem MediBlue Care On Site (HMO I-SNP)	Denver Metro Area		Denver Metro Area	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	1	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	024	0	2021	01	Anthem MediBlue Plus (HMO)	Nye County		Nye County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	025	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Clark,Nye, and Washoe Counties		Clark,Nye, and Washoe Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	026	0	2021	01	Anthem MediBlue Connect (HMO D-SNP)	Clark County		Clark County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	802	0	2021	01	Anthem EGWP MAPD (HMO)	Nevada		Nevada	1	3	1	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	caremore.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4346	805	0	2021	01	Anthem MediBlue (HMO)	Colorado - Select Counties		Colorado - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				4000000000208002100308002100408002100508002100608002100000000000	4000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	806	0	2021	01	Anthem MediBlue (HMO)	Colorado - Select Counties		Colorado - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				4000000000208002100308002100408002100508002100608002100000000000	4000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	809	0	2021	01	Anthem MediBlue (HMO)	Select Colorado Counties		Select Colorado Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												4000000000208002100308002100408002100508002100608002100000000000	4000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	810	0	2021	01	Anthem MediBlue (HMO)	Select Coloardo Counties		Select Coloardo Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	811	0	2021	01	Anthem MediBlue (HMO)	Select Colorado Counties		Select Colorado Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	812	0	2021	01	Anthem MediBlue (HMO)	Select Colorado Counties		Select Colorado Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	813	0	2021	01	Anthem MediBlue (HMO)	Select Colorado Counties		Select Colorado Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	821	0	2021	01	Anthem MediBlue (HMO)	Select Colorado Counties		Select Colorado Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/co/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.anthem.com/co/medicare	www.anthem.com/co/medicare	www.anthem.com/co/medicare
H4346	823	0	2021	01	Anthem MediBlue (HMO)	Nevada Select Counties		Nevada Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4346	824	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4346	825	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4346	826	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/Medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.anthem.com/Medicare	www.anthem.com/Medicare	www.anthem.com/Medicare
H4346	827	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4346	828	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4346	829	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4346	830	0	2021	01	Anthem MediBlue (HMO)	Nevada select counties		Nevada select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Anthem.com/Medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.Anthem.com/Medicare	www.Anthem.com/Medicare	www.Anthem.com/Medicare
H4388	001	0	2021	07	Secure Saver (MSA)	Wisconsin statewide		Wisconsin statewide	1	3	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpcsweb@securityhealth.org	shpcsweb@securityhealth.org									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.securityhealth.org/medicareadvantage	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0	www.securityhealth.org/securesaver	www.securityhealth.org/msapharmacies	www.securityhealth.org/securesaver
H4393	001	0	2021	20	ArchCare Senior Life - Dual (PACE)	New York, Bronx, Richmond and Westchester counties		New York, Bronx, Richmond and Westchester counties	1	3	0									1432 Fifth Avenue		New York	NY	10026		erosado@archcare.org	erosado@archcare.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ArchCareSeniorLife.org	0	0	1			0					3	0	0		www.archcareseniorlife.org	www.ArchCareSeniorLife.org
H4393	002	0	2021	20	ArchCare Senior Life - Medicare only (PACE)	New York, Bronx, Richmond and Westchester counties		New York, Bronx, Richmond and Westchester counties	1	3	0									1432 Fifth Avenue		New York	NY	10026		erosado@archcare.org	erosado@archcare.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ArchCareSeniorLife.org	0	0	1			0					3	0	0		www.archcareseniorlife.org	www.ArchCareSeniorLife.org
H4402	001	0	2021	20	Alexian Brothers Community Services (PACE)	Hamilton County Area		Hamilton County Area	1	3	0									425 Cumberland Street, Suite 110		Chattanooga	TN	37404		alison.crane@alexianbrothers.net	alison.crane@alexianbrothers.net	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.alexianpacetn.net	0	0	1			0					3	0	0		None	None
H4402	002	0	2021	20	Alexian Brothers Community Services (PACE)	Hamilton County Area		Hamilton County Area	1	3	0									425 Cumberland Street, Suite 110		Chattanooga	TN	37404		alison.crane@alexianbrothers.net	alison.crane@alexianbrothers.net	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.alexianpacetn.net	0	0	1			0					3	0	0		None	None
H4407	004	0	2021	01	Cigna TotalCare (HMO D-SNP)	Southern Mississippi	Cigna TotalCare (HMO D-SNP)	Southern Mississippi	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H4407	011	0	2021	01	Cigna Fundamental Medicare (HMO)	Southern Mississippi	Cigna Fundamental Medicare (HMO)	Southern Mississippi	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H4407	026	0	2021	01	Cigna Preferred Medicare (HMO)	Southern Mississippi	Cigna Preferred Medicare (HMO)	Southern Mississippi	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H4407	027	0	2021	01	Cigna Preferred Plus Medicare (HMO)	Southern Mississippi	Cigna Preferred Plus Medicare (HMO)	Southern Mississippi	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H4461	004	0	2021	02	Humana Honor (HMO-POS)	Greater Tennessee		Greater Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	022	0	2021	01	Humana Gold Plus SNP-DE H4461-022 (HMO D-SNP)	Greater Tennessee		Greater Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	025	0	2021	02	Humana Gold Plus H4461-025 (HMO-POS)	Memphis Metro Area		Memphis Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	029	0	2021	02	Humana Gold Plus H4461-029 (HMO-POS)	Nashville Metro Area		Nashville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	030	1	2021	02	Humana Gold Plus H4461-030 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	030	2	2021	02	Humana Gold Plus H4461-030 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	030	3	2021	02	Humana Gold Plus H4461-030 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	031	1	2021	02	Humana Gold Plus H4461-031 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	031	2	2021	02	Humana Gold Plus H4461-031 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	031	3	2021	02	Humana Gold Plus H4461-031 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	034	0	2021	02	Humana Gold Plus H4461-034 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	035	0	2021	02	Humana Gold Plus H4461-035 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	036	0	2021	02	Humana Gold Plus H4461-036 (HMO-POS)	East Tennessee		East Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	037	0	2021	02	Humana Gold Plus H4461-037 (HMO-POS)	Memphis Metro Area		Memphis Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	806	0	2021	01	Humana Medicare Employer (HMO)	Select counties in East Tennessee area		Select counties in East Tennessee area	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	807	0	2021	01	Humana Medicare Employer (HMO)	Select counties in East Tennessee area		Select counties in East Tennessee area	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	810	0	2021	01	Humana Medicare Employer (HMO)	Select counties in East Tennessee area		Select counties in East Tennessee area	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4461	811	0	2021	01	Humana Medicare Employer (HMO)	Select counties in East Tennessee area		Select counties in East Tennessee area	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4490	001	0	2021	01	American Health Advantage of Missouri (HMO I-SNP)	Missouri (partial)		Missouri (partial)	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	mo.AmHealthPlans.com	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	mo.AmHealthPlans.com	mo.AmHealthPlans.com	mo.AmHealthPlans.com
H4490	002	0	2021	01	American Health Advantage Plus of Missouri (HMO I-SNP)	Missouri (partial)		Missouri (partial)	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	mo.AmHealthPlans.com	1	1	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	mo.AmHealthPlans.com	mo.AmHealthPlans.com	mo.AmHealthPlans.com
H4497	001	1	2021	04	MedMutual Advantage Select (PPO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	001	2	2021	04	MedMutual Advantage Select (PPO)	Ohio Regions		Region 2	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	001	3	2021	04	MedMutual Advantage Select (PPO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	002	1	2021	04	MedMutual Advantage Preferred (PPO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	002	2	2021	04	MedMutual Advantage Preferred (PPO)	Ohio Regions		Region 2	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	002	3	2021	04	MedMutual Advantage Preferred (PPO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	003	1	2021	04	MedMutual Advantage Premium (PPO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	003	2	2021	04	MedMutual Advantage Premium (PPO)	Ohio Regions		Region 2	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	003	3	2021	04	MedMutual Advantage Premium (PPO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H4497	801	0	2021	04	MedMutual Advantage EGWP (Calendar Year) (PPO)	Ohio Regions		Ohio Regions	1	3	1	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medmutual.com/magroup	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	providersearch.medmutual.com	medmutual.com/magroup	medmutual.com/magroup
H4497	802	0	2021	04	MedMutual Advantage EGWP (Non-Calendar Year) (PPO)	Ohio Regions		Ohio Regions	1	3	1	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medmutual.com/magroup	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	providersearch.medmutual.com	medmutual.com/magroup	medmutual.com/magroup
H4497	803	0	2021	04	MedMutual Advantage EGWP (MA-Only) (PPO)	Ohio Regions		Ohio Regions	1	3	1	PO BOX 94563		Cleveland	OH	44101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medmutual.com/magroup	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	providersearch.medmutual.com	medmutual.com/magroup	medmutual.com/magroup
H4506	003	0	2021	01	WellCare TexanPlus Classic (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4506	010	0	2021	01	WellCare TexanPlus Value (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4506	029	0	2021	02	WellCare TexanPlus Choice (HMO-POS)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4506	801	0	2021	01	H4506 - Retiree - MA-PD non-CY (HMO)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4506	806	0	2021	01	City of Houston Group Retirees (HMO)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4506	808	0	2021	01	H4506 - Retiree - MA (HMO)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4506	810	0	2021	02	City of Houston Group Retirees (HMO-POS)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4513	009	0	2021	01	Cigna Fundamental Medicare (HMO)	Houston & Valley	Cigna Fundamental Medicare (HMO)	Houston & Valley	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	026	0	2021	01	Cigna Preferred Medicare (HMO)	East Texas	Cigna Preferred Medicare (HMO)	East Texas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	027	0	2021	01	Cigna TotalCare (HMO D-SNP)	East Texas	Cigna TotalCare (HMO D-SNP)	East Texas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	028	0	2021	01	Cigna Preferred Medicare (HMO)	North Texas & San Antonio	Cigna Preferred Medicare (HMO)	North Texas & San Antonio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	029	0	2021	01	Cigna TotalCare (HMO D-SNP)	North Texas & San Antonio	Cigna TotalCare (HMO D-SNP)	North Texas & San Antonio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	030	0	2021	01	Cigna Preferred Medicare (HMO)	Northwest Georgia	Cigna Preferred Medicare (HMO)	Northwest Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	033	0	2021	01	Cigna Fundamental Medicare (HMO)	Tennessee	Cigna Fundamental Medicare (HMO)	Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	034	0	2021	01	Cigna TotalCare (HMO D-SNP)	Middle and West Tennessee	Cigna TotalCare (HMO D-SNP)	Middle and West Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	035	0	2021	01	Cigna Primary Medicare (HMO)	East Tennessee	Cigna Primary Medicare (HMO)	East Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	036	0	2021	02	Cigna Premier Medicare (HMO-POS)	Tennessee	Cigna Premier Medicare (HMO-POS)	Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	037	0	2021	01	Cigna Preferred Medicare (HMO)	East Tennessee	Cigna Preferred Medicare (HMO)	East Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	038	0	2021	01	Cigna Preferred Medicare (HMO)	East Arkansas	Cigna Preferred Medicare (HMO)	East Arkansas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	039	0	2021	01	Cigna TotalCare (HMO D-SNP)	East Arkansas	Cigna TotalCare (HMO D-SNP)	East Arkansas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	040	0	2021	01	Cigna TotalCare (HMO D-SNP)	East Tennessee	Cigna TotalCare (HMO D-SNP)	East Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	042	0	2021	01	Cigna Alliance Medicare (HMO)	Middle Tennessee	Cigna Alliance Medicare (HMO)	Middle Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	043	0	2021	01	Cigna Preferred Plus Medicare (HMO)	Middle Tennessee	Cigna Preferred Plus Medicare (HMO)	Middle Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	045	0	2021	01	Cigna Fundamental Medicare (HMO)	Alabama	Cigna Fundamental Medicare (HMO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	046	1	2021	01	Cigna Preferred AL Medicare (HMO)	Alabama	Cigna Preferred AL Medicare (HMO)	South Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	046	2	2021	01	Cigna Preferred AL Medicare (HMO)	Alabama	Cigna Preferred AL Medicare (HMO)	North Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	047	0	2021	01	Cigna Preferred Plus Medicare (HMO)	Alabama	Cigna Preferred Plus Medicare (HMO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	048	0	2021	01	Cigna Preferred Plus Medicare (HMO)	Alabama	Cigna Preferred Plus Medicare (HMO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	049	1	2021	01	Cigna Preferred Medicare (HMO)	Tennessee	Cigna Preferred Medicare (HMO)	Tennessee Preferred	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	049	2	2021	01	Cigna Preferred Medicare (HMO)	Tennessee	Cigna Preferred Medicare (HMO)	Tennessee Preferred Select Counties	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	050	0	2021	01	Cigna Preferred Medicare (HMO)	Central Arkansas	Cigna Preferred Medicare (HMO)	Central Arkansas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	051	0	2021	01	Cigna Preferred Medicare (HMO)	West Arkansas	Cigna Preferred Medicare (HMO)	West Arkansas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	052	0	2021	01	Cigna Preferred Medicare (HMO)	Northwest Arkansas	Cigna Preferred Medicare (HMO)	Northwest Arkansas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	053	0	2021	01	Cigna Primary Medicare (HMO)	West Tennessee	Cigna Primary Medicare (HMO)	West Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	054	0	2021	01	Cigna Preferred Medicare (HMO)	Alabama	Cigna Preferred Medicare (HMO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	055	0	2021	01	Cigna TotalCare (HMO D-SNP)	Alabama	Cigna TotalCare (HMO D-SNP)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	056	1	2021	01	Cigna TotalCare AL (HMO D-SNP)	Alabama	Cigna TotalCare AL (HMO D-SNP)	South Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	056	2	2021	01	Cigna TotalCare AL (HMO D-SNP)	Alabama	Cigna TotalCare AL (HMO D-SNP)	North Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	057	0	2021	01	Cigna Preferred Medicare (HMO)	Alabama	Cigna Preferred Medicare (HMO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	059	0	2021	01	Cigna Preferred Medicare (HMO)	Tri Cities	Cigna Preferred Medicare (HMO)	Tri Cities	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	060	1	2021	01	Cigna TotalCare (HMO D-SNP)	Houston, Valley, El Paso & San Antonio	Cigna TotalCare (HMO D-SNP)	Houston & San Antonio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	060	2	2021	01	Cigna TotalCare (HMO D-SNP)	Houston, Valley, El Paso & San Antonio	Cigna TotalCare (HMO D-SNP)	Valley	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	060	3	2021	01	Cigna TotalCare (HMO D-SNP)	Houston, Valley, El Paso & San Antonio	Cigna TotalCare (HMO D-SNP)	El Paso	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	061	1	2021	01	Cigna Preferred Medicare (HMO)	Houston, Valley, El Paso & San Antonio	Cigna Preferred Medicare (HMO)	Houston & San Antonio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	061	2	2021	01	Cigna Preferred Medicare (HMO)	Houston, Valley, El Paso & San Antonio	Cigna Preferred Medicare (HMO)	Valley	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	061	3	2021	01	Cigna Preferred Medicare (HMO)	Houston, Valley, El Paso & San Antonio	Cigna Preferred Medicare (HMO)	El Paso	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	062	0	2021	01	Cigna Fundamental Medicare (HMO)	El Paso & San Antonio	Cigna Fundamental Medicare (HMO)	El Paso & San Antonio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	804	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide TX	Cigna Preferred Medicare (HMO)	Statewide TX	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignahealthspring.com
H4513	815	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide TN, MS & IL	Cigna Preferred Medicare (HMO)	Statewide TN, MS & IL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	817	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide AL	Cigna Preferred Medicare (HMO)	Statewide AL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	819	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide AR	Cigna Preferred Medicare (HMO)	Statewide AR	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	820	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide VA	Cigna Preferred Medicare (HMO)	Statewide VA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4513	821	0	2021	01	Cigna Preferred Medicare (HMO)	Nationwide	Cigna Preferred Medicare (HMO)	Nationwide	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H4514	007	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Houston Metro area		Houston Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4514	013	1	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Houston, Austin, and Outer Dallas Metro Areas		Houston Metro Area	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4514	013	2	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Houston, Austin, and Outer Dallas Metro Areas		Austin Metro Area	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4514	013	3	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Houston, Austin, and Outer Dallas Metro Areas		Outer Dallas Metro Area	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4514	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area		TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4514	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area		TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4514	806	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area		TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4517	001	0	2021	20	DUAL ELIGIBLE (PACE)	Potter, TX and Randall, TX Counties		Potter, TX and Randall, TX Counties	1	3	0									3108 S Fillmore		Amarillo	TX	79110		krissy@janwerneradultdaycare.org	krissy@janwerneradultdaycare.org	3100001200200001200300001200400001200500001200600001200700001200	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.janwerneradultdaycare.org	0	0	1			0					3	0	0		N/A	N/A
H4517	002	0	2021	20	MEDICARE ONLY (PACE)	Potter, TX and Randall, TX Counties		Potter, TX and Randall, TX Counties	1	3	0									3108 S Fillmore		Amarillo	TX	79110		Krissy@janwerneradultdaycare.org	Krissy@janwerneradultdaycare.org	3100001200200001200300001200400001200500001200600001200700001200	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.janwerneradultdaycare.org	0	0	1			0					3	0	0		N/A	N/A
H4518	001	0	2021	20	BSHS Part D, Dual Eligibles (PACE)	El Paso, Texas and El Paso County		El Paso, Texas and El Paso County	1	3	0									2300 McKinley		El Paso	TX	79930		rorona@bienvivir.org	rorona@bienvivir.org	4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Bienvivir.org	0	0	1			0					3	0	0		www.bienvivir.org	www.bienvivir.org
H4518	002	0	2021	20	BSHS Part D, Medicare Only (PACE)	El Paso, Texas and El Paso County		El Paso, Texas and El Paso County	1	3	0									2300 McKinley		El Paso	TX	79930		rorona@bienvivir.org	rorona@bienvivir.org	4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Bienvivir.org	0	0	1			0					3	0	0		www.bienvivir.org	www.bienvivir.org
H4523	001	0	2021	01	Aetna Medicare Premier Plan (HMO)	San Antonio and Austin Counties		San Antonio and Austin Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4523	015	0	2021	01	Aetna Medicare Premier Plan (HMO)	Houston and Surrounding Counties		Houston and Surrounding Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4523	020	0	2021	01	Aetna Medicare Prime Plan (HMO)	Bexar and Comal counties		Bexar and Comal counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4523	021	0	2021	01	Aetna Medicare Prime Plan (HMO)	Dallas and Surrounding Counties		Dallas and Surrounding Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4523	024	0	2021	01	Aetna Medicare Prime Plan (HMO)	Harris County		Harris County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4523	801	0	2021	01	Aetna Medicare Plan (HMO)	Texas		Texas	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4523	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Texas		Texas	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4527	001	0	2021	01	AARP Medicare Advantage (HMO)	Select Counties in Texas		Select Counties in Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4527	002	0	2021	01	AARP Medicare Advantage (HMO)	Austin Metro Area		Austin Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4527	003	0	2021	01	UnitedHealthcare Dual Complete Focus (HMO D-SNP)	Hays, Travis, and Williamson counties		Hays, Travis, and Williamson counties	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4527	004	0	2021	01	UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)	Aransas, Kleberg, Nueces, San Patricio counties		Aransas, Kleberg, Nueces, San Patricio counties	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4527	005	0	2021	01	AARP Medicare Advantage (HMO)	El Paso County		El Paso County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4527	006	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	El Paso County		El Paso County	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4527	013	0	2021	01	AARP Medicare Advantage (HMO)	Brownsville Metro Area		Brownsville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4527	015	0	2021	01	UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)	Cameron, Hidalgo, and Willacy counties		Cameron, Hidalgo, and Willacy counties	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4527	024	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	Select counties in Texas		Select counties in Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4527	037	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Houston Metro Area		Houston Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4527	039	0	2021	01	UnitedHealthcare Chronic Complete (HMO C-SNP)	Bastrop, Hays, Travis, and Williamson counties		Bastrop, Hays, Travis, and Williamson counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4527	040	0	2021	01	UnitedHealthcare Chronic Complete (HMO C-SNP)	El Paso County		El Paso County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4527	041	0	2021	01	UnitedHealthcare Chronic Complete (HMO C-SNP)	Corpus Christi Metro Area		Corpus Christi Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4527	042	0	2021	01	UnitedHealthcare Chronic Complete (HMO C-SNP)	Cameron, Hidalgo, Starr, and Willacy Counties		Cameron, Hidalgo, Starr, and Willacy Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4527	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area		TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4527	802	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area		TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4527	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area		TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4544	001	0	2021	04	Peoples Health Choices (PPO)	Select Counties in Louisiana		Select Counties in Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H4544	002	0	2021	04	Peoples Health Patriot (PPO)	Select Counties in Louisiana		Select Counties in Louisiana	1	0	0	Three Lakeway Center	3838 N Causeway Blvd, Suite 2200	Metairie	LA	70002		salesprocessing@peopleshealth.com	PHN.member@peopleshealth.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.peopleshealth.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.peopleshealth.com/physicians	www.peopleshealth.com/pharmacies	www.peopleshealth.com/formulary
H4556	999	0	2021	19	Consolidated Assoc Of Railroad Employees Hc	Consolidated Assoc Of Railroad Employees Hc		Consolidated Assoc Of Railroad Employees Hc	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.			0	0	2			0					3	0	0			
H4590	010	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	San Antonio Metro area	AARP Medicare Advantage SecureHorizons (HMO)	San Antonio Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	012	0	2021	02	AARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS)	Dallas/Fort Worth Metroplex	AARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS)	Dallas/Fort Worth Metroplex	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	020	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Dallas/Ft Worth Metroplex	UnitedHealthcare Dual Complete (HMO D-SNP)	Dallas/Ft Worth Metroplex	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4590	022	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	San Antonio Metro area	UnitedHealthcare Dual Complete (HMO D-SNP)	San Antonio Metro area	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4590	025	0	2021	01	AARP Medicare Advantage SecureHorizons (HMO)	Corpus Christi Metro Area	AARP Medicare Advantage SecureHorizons (HMO)	Corpus Christi Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	027	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	Dallas/Ft Worth Metroplex	AARP Medicare Advantage Patriot (HMO-POS)	Dallas/Ft Worth Metroplex	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	029	0	2021	01	AARP Medicare Advantage Patriot (HMO)	San Antonio Metro area	AARP Medicare Advantage Patriot (HMO)	San Antonio Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	033	0	2021	01	UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)	Corpus Christi metro area	UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)	Corpus Christi metro area	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H4590	037	0	2021	01	UnitedHealthcare Chronic Complete (HMO C-SNP)	San Antonio Metro Area	UnitedHealthcare Chronic Complete (HMO C-SNP)	San Antonio Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4590	041	0	2021	02	AARP Medicare Advantage SecureHorizons Plan 2 (HMO-POS)	Dallas/Ft Worth Metroplex		Dallas/Ft Worth Metroplex	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	042	0	2021	02	AARP Medicare Advantage (HMO-POS)	Select Counties in Texas		Select Counties in Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	043	0	2021	02	AARP Medicare Advantage (HMO-POS)	Dallas Metro Area		Dallas Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4590	044	0	2021	02	UnitedHealthcare Medicare Advantage Ally (HMO-POS C-SNP)	Dallas Metro Area		Dallas Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	4	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4590	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4590	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4590	804	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area	UnitedHealthcare Group Medicare Advantage (HMO)	TX Employer Sponsored Plan Service Area	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4604	003	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	005	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	011	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	012	0	2021	01	AARP Medicare Advantage (HMO)	Ada, Canyon, Gem, and Payette Counties		Ada, Canyon, Gem, and Payette Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	013	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Bonner and Kootenai Counties		Bonner and Kootenai Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	014	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	015	0	2021	01	AARP Medicare Advantage Focus (HMO)	Ada, Canyon, and Gem Counties		Ada, Canyon, and Gem Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	016	0	2021	01	AARP Medicare Advantage (HMO)	Iron and Washington County		Iron and Washington County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	017	0	2021	01	UnitedHealthcare Medicare Advantage Assist (HMO C-SNP)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4604	018	0	2021	01	AARP Medicare Advantage Walgreens (HMO)	Select Counties in Utah		Select Counties in Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	019	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select counties in Idaho		Select counties in Idaho	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	020	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select counties in Idaho		Select counties in Idaho	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4604	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Salt Lake and Surrounding Counties		Salt Lake and Surrounding Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4604	803	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select Counties In UT		Select Counties In UT	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4604	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in UT		Select counties in UT	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H4605	001	0	2021	04	Regence Valiance (PPO)	Select Counties in Utah		Select Counties in Utah	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	002	0	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Select Counties in Utah		Select Counties in Utah	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	004	0	2021	04	Regence MedAdvantage + Rx Enhanced (PPO)	Davis, Salt Lake, Utah, and Weber counties		Davis, Salt Lake, Utah, and Weber counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	007	0	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Select Counties in Utah		Select Counties in Utah	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	008	0	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Iron and Washington Counties		Iron and Washington Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	009	0	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Iron and Washington Counties		Iron and Washington Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	801	0	2021	04	Regence MedAdvantage (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	802	0	2021	04	Regence MedAdvantage + Rx (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	803	0	2021	04	Regence MedAdvantage + Rx 02 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4605	804	0	2021	04	Regence MedAdvantage + Rx 03 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H4623	001	0	2021	01	Humana Gold Plus H4623-001 (HMO)	Southwest Missouri		Southwest Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4623	002	0	2021	01	Humana Community HMO H4623-002 (HMO)	Greene, Christian, Webster counties		Greene, Christian, Webster counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H4624	001	0	2021	01	Zing Choice IL (HMO)	Kane & Will Counties & Rockford Area	Zing Choice IL (HMO)	Kane & Will Counties & Rockford Area	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	002	0	2021	02	Zing Open Access IL (HMO-POS)	Kane & Will Counties & Rockford Area	Zing Open Access IL (HMO-POS)	Kane & Will Counties & Rockford Area	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	003	0	2021	01	Zing Choice IN (HMO)	Allen County	Zing Choice IN (HMO)	Allen County	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	004	0	2021	01	Zing Choice IN (HMO)	Lake County	Zing Choice IN (HMO)	Lake County	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	005	0	2021	01	Zing Choice IN (HMO)	Marion County	Zing Choice IN (HMO)	Marion County	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	006	0	2021	01	Zing Choice MI (HMO)	Genesee, Oakland & Wayne Counties	Zing Choice MI (HMO)	Genesee, Oakland & Wayne Counties	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	007	0	2021	02	Zing Open Access MI (HMO-POS)	Genesee, Oakland & Wayne Counties	Zing Open Access MI (HMO-POS)	Genesee, Oakland & Wayne Counties	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	010	0	2021	01	Zing Essential Wellness IL (HMO C-SNP)	Cook, Kane & Will Counties & Rockford Area	Zing Essential Wellness IL (HMO C-SNP)	Cook, Kane & Will Counties & Rockford Area	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	011	0	2021	01	Zing Essential Wellness IN (HMO C-SNP)	Allen, Lake & Marion Counties	Zing Essential Wellness IN (HMO C-SNP)	Allen, Lake & Marion Counties	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	012	0	2021	01	Zing Essential Wellness MI (HMO C-SNP)	Genesee, Oakland & Wayne Counties	Zing Essential Wellness MI (HMO C-SNP)	Genesee, Oakland & Wayne Counties	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	801	0	2021	01	Zing EGWP CY (HMO)	Counties in IL, IN, MI	Zing EGWP CY (HMO)	Counties in IL, IN, MI	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	802	0	2021	01	Zing EGWP NCY (HMO)	Counties in IL, IN, MI	Zing EGWP NCY (HMO)	Counties in IL, IN, MI	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	803	0	2021	01	Zing EGWP MA Only CY (HMO)	Counties in IL, IN, MI	Zing EGWP MA Only CY (HMO)	Counties in IL, IN, MI	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com									2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4624	804	0	2021	01	Zing EGWP MA Only NCY (HMO)	Counties in IL, IN, MI	Zing EGWP MA Only NCY (HMO)	Counties in IL, IN, MI	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com									2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H4652	999	0	2021	19	Union Pacific Railroad Employes Health Systems	Union Pacific Railroad Employes Health Systems		Union Pacific Railroad Employes Health Systems	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.		www.uphealth.com	0	0	2			0					3	0	0			
H4675	001	0	2021	01	Braven Medicare Plus (HMO)	Eastern New Jersey		Eastern New Jersey	1	0	0	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H4675	801	0	2021	02	Braven Medicare Access Group (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bravenhealth.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H4675	802	0	2021	02	Braven Medicare Access Group w/Rx (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H4675	803	0	2021	02	Braven Medicare Access Group w/Rx Value (HMO-POS)	New Jersey		New Jersey	1	3	1	3 Penn Plaza East	PP- 12F	Newark	NJ	07105				3 Penn Plaza East	PP- 12F	Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bravenhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bravenhealth.com	https://www.bravenhealth.com	https://www.bravenhealth.com
H4676	001	0	2021	01	Troy Medicare (HMO)	Cabarrus, Iredell, Rowan, and Robeson		Cabarrus, Iredell, Rowan, and Robeson	1	0	0	P.O. Box 30516		Charlotte	NC	28230		contact@troymedicare.com	contact@troymedicare.com	P.O. Box 30516		Charlotte	NC	28230		contact@troymedicare.com	info@performrx.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.troymedicare.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.troymedicare.com	www.troymedicare.com	www.troymedicare.com
H4676	002	0	2021	01	Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)	Robeson		Robeson	1	0	0	P.O. Box 30516		Charlotte	NC	28230		contact@troymedicare.com	contact@troymedicare.com	P.O. Box 30516		Charlotte	NC	28230		contact@troymedicare.com	info@performrx.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.troymedicare.com	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.troymedicare.com	www.troymedicare.com	www.troymedicare.com
H4699	001	0	2021	04	WellCare Premier (PPO)	All counties in RI		All counties in RI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4699	002	0	2021	04	WellCare Absolute (PPO)	All counties in RI		All counties in RI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4699	003	0	2021	04	WellCare Imperial (PPO D-SNP)	All counties in RI		All counties in RI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4709	001	0	2021	01	Bright Advantage Health Dollars (HMO)	Daytona Beach Area		Daytona Beach Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4709	003	0	2021	01	Bright Advantage Health Dollars (HMO)	Orlando Area		Orlando Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4709	011	0	2021	01	Bright Advantage Health Dollars (HMO)	Fort Lauderdale Area		Fort Lauderdale Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4709	024	0	2021	01	Bright Advantage Health Dollars (HMO)	Palm Beach Area		Palm Beach Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4709	025	0	2021	01	Bright Advantage Health Dollars (HMO)	Central Florida		Central Florida	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4711	001	0	2021	01	Aetna Medicare Premier Plan (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	002	0	2021	01	Aetna Medicare Prime Plan (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	005	0	2021	01	Aetna Medicare Premier Plan (HMO)	Northern Nevada		Northern Nevada	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	006	0	2021	01	Aetna Medicare Elite Prime (HMO)	Denver Metro		Denver Metro	1	0	0	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	007	0	2021	01	Aetna Medicare Elite Prime (HMO)	Southern Colorado		Southern Colorado	1	0	0	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	008	0	2021	01	Aetna Medicare Prime 1 (HMO)	Denver Metro		Denver Metro	1	0	0	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	009	0	2021	01	Aetna Medicare Prime 1 (HMO)	Southern Colorado		Southern Colorado	1	0	0	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	010	0	2021	01	Aetna Medicare Eagle Prime (HMO)	Colorado		Colorado	1	0	0	P.O. Box 7405		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	011	0	2021	01	Aetna Medicare Prime Plan (HMO D-SNP)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	801	0	2021	01	Aetna Medicare Plan (HMO)	Colorado and Nevada		Colorado and Nevada	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4711	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Colorado and Nevada		Colorado and Nevada	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4714	001	0	2021	20	PACE of the Southern Piedmont - Dual (PACE)	PACE of the Southern Piedmont - Dual		PACE of the Southern Piedmont - Dual	1	3	0									6133 The Plaza		Charlotte	NC	28215		renee.rizzuti@pacesp.com	renee.rizzuti@pacesp.com	2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacesp.com	0	0	1			0					3	0	0		http://pharmastarpbm.com	Notapplicable
H4714	002	0	2021	20	PACE of the Southern Piedmont - Medicare only (PACE)	PACE of the Southern Piedmont - Medicare only		PACE of the Southern Piedmont - Medicare only	1	3	0									6133 The Plaza		Charlotte	NC	28215		renee.rizzuti@pacesp.com	renee.rizzuti@pacesp.com	2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacesp.com	0	0	1			0					3	0	0		http://pharmastarpbm.com	Notapplicable
H4754	004	0	2021	04	PacificSource Medicare Explorer Rx 4 (PPO)	Lane County		Lane County	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	006	0	2021	04	PacificSource Medicare Explorer 6 (PPO)	Southwest and Southern Idaho		Southwest and Southern Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	007	0	2021	04	PacificSource Medicare Explorer Rx 7 (PPO)	Coos and Curry Counties		Coos and Curry Counties	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	008	0	2021	04	PacificSource Medicare Explorer 8 (PPO)	Coos, Curry and Lane Counties		Coos, Curry and Lane Counties	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	009	0	2021	04	PacificSource Medicare Explorer Rx 9 (PPO)	Eastern Idaho		Eastern Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	011	0	2021	04	PacificSource Medicare Explorer Rx 11 (PPO)	North Idaho		North Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	012	0	2021	04	PacificSource Medicare Explorer 12 (PPO)	North and Eastern Idaho		North and Eastern Idaho	1	0	0	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	016	0	2021	04	PacificSource Medicare Explorer 16 (PPO)	Missoula County		Missoula County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	017	0	2021	04	PacificSource Medicare Explorer Rx 17 (PPO)	Missoula County		Missoula County	1	0	0	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Ave		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	801	0	2021	04	PacificSource Medicare Explorer 801 (PPO)	Statewide - Idaho, Montana and Oregon		Statewide - Idaho, Montana and Oregon	1	3	1	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com									4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4754	802	0	2021	04	PacificSource Medicare Explorer Rx 802 (PPO)	Statewide - Idaho, Montana and Oregon		Statewide - Idaho, Montana and Oregon	1	3	1	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	2965 NE Conners Avenue		Bend	OR	97701			MedicareCS@PacificSource.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Medicare.PacificSource.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	https://medicare.pacificsource.com/Search/Provider	https://medicare.pacificsource.com/Search/Pharmacy	https://medicare.pacificsource.com/Search/Drug
H4829	002	0	2021	04	AARP Medicare Advantage Choice (PPO)	Napa and Sonoma County		Napa and Sonoma County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4829	003	0	2021	04	AARP Medicare Advantage Choice (PPO)	Lake, Mendocino and Tulare County		Lake, Mendocino and Tulare County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4829	004	0	2021	04	AARP Medicare Advantage Choice (PPO)	Marin and Solano County		Marin and Solano County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H4835	001	0	2021	01	Aetna Medicare Prime Plus Plan (HMO)	Maricopa County		Maricopa County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	002	0	2021	01	Aetna Medicare Premier Plan (HMO)	Maricopa County		Maricopa County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	003	0	2021	01	Aetna Medicare Premier Plan (HMO)	Pinal County		Pinal County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	004	0	2021	01	Aetna Medicare Premier Plan (HMO)	Pima County		Pima County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	005	0	2021	01	Aetna Medicare Premier Plan (HMO)	Mohave and Yavapai Counties		Mohave and Yavapai Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	006	0	2021	01	Aetna Medicare Premier Plan (HMO)	CHS, CNO, GLA, GHM and SCZ		CHS, CNO, GLA, GHM and SCZ	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	801	0	2021	01	Aetna Medicare Plan (HMO)	Arizona		Arizona	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4835	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Arizona		Arizona	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4847	001	0	2021	01	WellCare Elite (HMO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4847	002	0	2021	01	WellCare Elite (HMO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4847	003	0	2021	01	WellCare Plus (HMO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4847	004	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4847	005	0	2021	01	WellCare Compass (HMO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4847	006	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4853	001	0	2021	01	Bright Advantage (HMO)	Phoenix Area		Phoenix Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4853	002	0	2021	01	Bright Advantage Assist (HMO)	Phoenix Area		Phoenix Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4853	014	0	2021	01	Bright Advantage Plus (HMO)	Phoenix Area		Phoenix Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H4868	002	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	003	0	2021	01	WellCare Patriot (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	004	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	010	0	2021	01	WellCare Preferred (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	014	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	016	0	2021	01	WellCare Compass (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	018	0	2021	01	WellCare Value (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	019	0	2021	01	WellCare Value (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	020	0	2021	01	WellCare Choice (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4868	022	0	2021	01	WellCare Element (HMO)	Select counties in NY		Select counties in NY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H4875	016	1	2021	04	PriorityMedicare Merit (PPO)	68 lower peninsula Michigan counties		Region 3	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	016	2	2021	04	PriorityMedicare Merit (PPO)	68 lower peninsula Michigan counties		Region 4	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	016	3	2021	04	PriorityMedicare Merit (PPO)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	016	4	2021	04	PriorityMedicare Merit (PPO)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	016	5	2021	04	PriorityMedicare Merit (PPO)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	017	1	2021	04	PriorityMedicare Select (PPO)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	017	2	2021	04	PriorityMedicare Select (PPO)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	017	3	2021	04	PriorityMedicare Select (PPO)	68 lower peninsula Michigan counties		Region 3	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	017	4	2021	04	PriorityMedicare Select (PPO)	68 lower peninsula Michigan counties		Region 4	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	017	5	2021	04	PriorityMedicare Select (PPO)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	018	1	2021	04	PriorityMedicare Ideal (PPO)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	018	2	2021	04	PriorityMedicare Ideal (PPO)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	018	3	2021	04	PriorityMedicare Ideal (PPO)	68 lower peninsula Michigan counties		Region 3	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	018	4	2021	04	PriorityMedicare Ideal (PPO)	68 lower peninsula Michigan counties		Region 4	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	018	5	2021	04	PriorityMedicare Ideal (PPO)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	020	1	2021	04	PriorityMedicare Edge (PPO)	West, SW, & SE counties, lower MI		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	020	2	2021	04	PriorityMedicare Edge (PPO)	West, SW, & SE counties, lower MI		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	020	3	2021	04	PriorityMedicare Edge (PPO)	West, SW, & SE counties, lower MI		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	021	1	2021	04	PriorityMedicare Compass (PPO)	North counties, lower MI		Region 3	1	0	0	1231 East Beltline		Grand Rapids	MI	49525				1231 East Beltline		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	021	2	2021	04	PriorityMedicare Compass (PPO)	North counties, lower MI		Region 4	1	0	0	1231 East Beltline		Grand Rapids	MI	49525				1231 East Beltline		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	022	1	2021	04	PriorityMedicare Vital (PPO)	68 lower peninsula Michigan counties		Region 1	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	022	2	2021	04	PriorityMedicare Vital (PPO)	68 lower peninsula Michigan counties		Region 2	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	022	5	2021	04	PriorityMedicare Vital (PPO)	68 lower peninsula Michigan counties		Region 5	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	803	0	2021	04	PriorityMedicare PPO EG Non-Calendar Year (PPO)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	804	0	2021	04	PriorityMedicare PPO EG Calendar Year (PPO)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	805	0	2021	04	PriorityMedicare PPO No RX EGWP Calendar (PPO)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4875	806	0	2021	04	PriorityMedicare PPO No RX EGWP Non-Calendar (PPO)	National		National	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.prioritymedicare.com	www.prioritymedicare.com	www.prioritymedicare.com
H4882	001	0	2021	04	HealthPartners Journey Stride (PPO)	Metro and Central MN Counties		Metro and Central MN Counties	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	002	0	2021	04	HealthPartners Journey Pace (PPO)	Metro and Central MN Counties		Metro and Central MN Counties	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	003	0	2021	04	HealthPartners Journey Steady (PPO)	Metro and Central MN Counties		Metro and Central MN Counties	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	004	0	2021	04	HealthPartners Robin Birch (PPO)	NE WI - Brown, Outagamie: 13 additional counties		NE WI - Brown, Outagamie: 13 additional counties	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	005	0	2021	04	HealthPartners Robin Maple (PPO)	NE WI - Brown, Outagamie: 13 additional counties		NE WI - Brown, Outagamie: 13 additional counties	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	006	0	2021	04	HealthPartners Journey Dash (PPO)	Metro and Central MN Counties		Metro and Central MN Counties	1	0	0	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	801	0	2021	04	HealthPartners Group MAPD Calendar Year (PPO)	All States Excluding Cost Counties		All States Excluding Cost Counties	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	803	0	2021	04	HealthPartners Group MA Only (PPO)	All States Excluding Cost Counties		All States Excluding Cost Counties	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	804	0	2021	04	HealthPartners Group II MAPD Calendar Year (PPO)	All States Excluding Cost Counties		All States Excluding Cost Counties	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425				8170 33rd Avenue South		Bloomington	MN	55425				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4882	805	0	2021	04	HealthPartners Group II MA Only (PPO)	All States Excluding Cost Counties		All States Excluding Cost Counties	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	healthpartners.com/medicarenetworks	healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
H4906	999	0	2021	19	C and O Employees' Hospital Association	C and O Employees' Hospital Association		C and O Employees' Hospital Association	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.		www.coeha.com	0	0	2			0					3	0	0			
H4909	014	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 14046		Roanoke	VA	24038		direct.sales.va@wellpoint.com		P.O. Box 14046		Roanoke	VA	24038		direct.sales.va@wellpoint.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4909	015	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		4361 Irwin Simpson Road	OH0205-037	Mason	OH	45040				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4909	016	0	2021	04	Anthem MediBlue Access Basic (PPO)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	1351 William Howard Taft	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		4361 Irwin Simpson Road	OH0205-037	Mason	OH	45040		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4909	018	0	2021	04	Anthem MediBlue Dual Access (PPO D-SNP)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	P.O. Box 14046		Roanoke	VA	24038		direct.sales.va@wellpoint.com		P.O. Box 14046		Roanoke	VA	24038		direct.sales.va@wellpoint.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H4909	804	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	805	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	806	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	810	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	811	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	812	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	813	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	814	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	815	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	816	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	817	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4909	818	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H4922	003	0	2021	01	AgeWell New York FeelWell (HMO D-SNP)	New York City Metro Area, Nassau, Westchester		New York City Metro Area, Nassau, Westchester	1	0	0	1991 Marcus Ave	Suite M201	Lake Success	NY	11042				1991 Marcus Ave	Suite M201	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.agewellnewyork.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.agewellnewyork.com	www.agewellnewyork.com	www.agewellnewyork.com
H4922	004	0	2021	01	AgeWell New York CareWell (HMO I-SNP)	New York City Metro Area, Long Island, Westchester		New York City Metro Area, Long Island, Westchester	1	0	0	1991 Marcus Ave	Suite M201	Lake Success	NY	11042				1991 Marcus Ave	Suite M201	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.agewellnewyork.com	1	1	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.agewellnewyork.com	www.agewellnewyork.com	www.agewellnewyork.com
H4922	010	0	2021	01	AgeWell New York Advantage Plus (HMO D-SNP)	New York City Metro Area, Nassau, Westchester		New York City Metro Area, Nassau, Westchester	1	0	0	1991 Marcus Ave	Suite M201	Lake Success	NY	11042				1991 Marcus Ave	Suite M201	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.agewellnewyork.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.agewellnewyork.com	www.agewellnewyork.com	www.agewellnewyork.com
H4922	011	0	2021	01	AgeWell New York LiveWell (HMO)	New York City Metro Area, Nassau, Westchester		New York City Metro Area, Nassau, Westchester	1	0	0	1991 Marcus Ave	Suite M201	Lake Success	NY	11042				1991 Marcus Ave	Suite M201	Lake Success	NY	11042				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.agewellnewyork.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.agewellnewyork.com	www.agewellnewyork.com	www.agewellnewyork.com
H4931	001	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	Cochise, Gila, Graham, Greenlee, La Paz	Banner - University Care Advantage (HMO D-SNP)	Cochise, Gila, Graham, Greenlee, La Paz	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	006	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	Pima County	Banner - University Care Advantage (HMO D-SNP)	Pima County	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	007	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	Pinal, Maricopa	Banner - University Care Advantage (HMO D-SNP)	Pinal, Maricopa	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	008	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	Santa Cruz, Yuma	Banner - University Care Advantage (HMO D-SNP)	Santa Cruz, Yuma	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	013	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Cochise, Gila, Graham, Greenlee, La Paz	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Cochise, Gila, Graham, Greenlee, La Paz	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	014	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Pima	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Pima	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	015	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Maricopa, Pinal	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Maricopa, Pinal	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4931	016	0	2021	01	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Santa Cruz, Yuma	Banner - University Care Advantage (HMO D-SNP)	ALTCS: Santa Cruz, Yuma	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.banneruca.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.banneruca.com/find-a-provider	www.banneruca.com/find-a-pharmacy	www.banneruca.com/plan-information/2021-plan-materials#Drug-Formulary
H4937	001	0	2021	04	Blue Shield Inspire (PPO)	Alameda County	Blue Shield Inspire (PPO)	Alameda County	1	0	0	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H4937	801	0	2021	04	Blue Shield Medicare (PPO)	MA-PD Employer Group Plan	Blue Shield Medicare (PPO)	MA-PD Employer Group Plan	1	3	1	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H4937	802	0	2021	04	Blue Shield Medicare (PPO)	MA-PD Employer Group Plan	Blue Shield Medicare (PPO)	MA-PD Employer Group Plan	1	3	1	6300 Canoga Avenue		Woodland HIlls	CA	91367				6300 Canoga Avenue		Woodland HIlls	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H4961	001	0	2021	04	My Choice (PPO)	Sacramento, Placer & Yolo Counties		Sacramento, Placer & Yolo Counties	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4961	002	0	2021	04	My Choice (PPO)	San Mateo County		San Mateo County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4961	003	0	2021	04	My Choice (PPO)	Sonoma County		Sonoma County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4961	004	0	2021	04	My Choice (PPO)	San Joaquin, Stanislaus and Santa Cruz		San Joaquin, Stanislaus and Santa Cruz	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4961	006	0	2021	04	Balance (PPO)	San Joaquin and Stanislaus		San Joaquin and Stanislaus	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4961	801	0	2021	04	Retiree Options (PPO)	Sac, Placer, Yolo, SM, Sonoma, ST & SJ, Santa Cruz		Sac, Placer, Yolo, SM, Sonoma, ST & SJ, Santa Cruz	1	3	1	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4961	802	0	2021	04	Retiree Options (PPO)	Sac, Placer, Yolo, SM, Sonoma, ST & SJ, Santa Cruz		Sac, Placer, Yolo, SM, Sonoma, ST & SJ, Santa Cruz	1	3	1	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H4982	001	0	2021	01	Aetna Medicare Plus Plan (HMO)	Los Angeles and Orange Counties		Los Angeles and Orange Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	002	0	2021	01	Aetna Medicare Plus Plan (HMO)	Riverside and San Bernardino Counties		Riverside and San Bernardino Counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	003	0	2021	01	Aetna Medicare Plus Plan (HMO)	Kern County		Kern County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	004	0	2021	01	Aetna Medicare Plus Plan (HMO)	San Diego County		San Diego County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	005	0	2021	01	Aetna Medicare Plus Plan (HMO)	Alameda County		Alameda County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	006	0	2021	01	Aetna Medicare Plus Plan (HMO)	Santa Clara County		Santa Clara County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	007	0	2021	01	Aetna Medicare Plus Plan (HMO)	San Francisco County		San Francisco County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	008	0	2021	01	Aetna Medicare Preferred Plan (HMO D-SNP)	Northern California		Northern California	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	009	0	2021	01	Aetna Medicare Preferred Plan (HMO D-SNP)	Southern California		Southern California	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	010	0	2021	01	Aetna Medicare Plus Plan (HMO)	Fresno County		Fresno County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	011	0	2021	01	Aetna Medicare Plus Plan (HMO)	Marin County		Marin County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	012	0	2021	01	Aetna Medicare Plus Plan (HMO)	Ventura County		Ventura County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	013	0	2021	01	Aetna Medicare Eagle Plan (HMO)	California		California	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	015	0	2021	01	Aetna Medicare Plus Plan 2 (HMO)	San Diego County		San Diego County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	801	0	2021	01	Aetna Medicare Plan (HMO)	California		California	1	3	1	151 Farmington Avenue		Hartford	CT	06156												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4982	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	California		California	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H4999	001	0	2021	20	LIFE Northwestern Pennsylvania (PACE)	Counties: Erie, War, Craw, Mer, Ven, McK, For, Cla		Counties: Erie, War, Craw, Mer, Ven, McK, For, Cla	1	3	0									LIFE-NWPA Attn: Part-D Administration	149 West 22nd. St.	Erie	PA	16502			wfeldmann@vals.org	2000000000209001600309001600409001600509001600609001600000000000	2000000000209001600309001600409001600509001600609001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifenwpa.org	0	0	1			0					3	0	0		www.lifenwpa.org	www.lifenwpa.org
H4999	002	0	2021	20	LIFE Northwestern Pennsylvania (PACE)	Counties: Erie, War, Craw, Mer, Ven, McK, For, Cla		Counties: Erie, War, Craw, Mer, Ven, McK, For, Cla	1	3	0									LIFE-NWPA Attn: Part-D Administration	149 West 22nd. St.	Erie	PA	16502		wfeldmann@vals.org	wfeldmann@vals.org	2000000000209001600309001600409001600509001600609001600000000000	2000000000209001600309001600409001600509001600609001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifenwpa.org	0	0	1			0					3	0	0		www.lifenwpa.org	www.lifenwpa.org
H5007	001	0	2021	20	Providence ElderPlace - Seattle (PACE)	Seattle - King County Washington		Seattle - King County Washington	1	3	0									4515 Martin Luther King Jr. Way S. Ste. 100		Seattle	WA	98108				5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	washington.providence.org/senior-care/elderplace	0	0	1			0					3	0	0		www.providence.org/longtermcare/elderplace	www.providence.org/longtermcare/elderplace
H5007	002	0	2021	20	Providence ElderPlace - Seattle (PACE)	Seattle - King County Washington		Seattle - King County Washington	1	3	0									4515 Martin Luther King Jr. Way S. Ste. 100		Seattle	WA	98108				5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	washington.providence.org/senior-care/elderplace	0	0	1			0					3	0	0		www.providence.org/longtermcare/elderplace	www.providence.org/longtermcare/elderplace
H5008	001	0	2021	02	UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)	King, Kitsap, Pierce, and Snohomish Counties		King, Kitsap, Pierce, and Snohomish Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5008	002	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Washington		Select Counties in Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5008	010	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	New Orleans Metro area		New Orleans Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5008	011	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5009	001	0	2021	04	Regence Valiance (PPO)	Select Counties in Washington		Select Counties in Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	002	0	2021	04	Regence MedAdvantage + Rx Enhanced (PPO)	Select Counties in Washington		Select Counties in Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	008	0	2021	04	Regence MedAdvantage + Rx Classic (PPO)	Select Counties in Washington		Select Counties in Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	009	0	2021	04	Regence MedAdvantage + Rx Primary (PPO)	Select Counties in Washington		Select Counties in Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	801	0	2021	04	Regence MedAdvantage (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	802	0	2021	04	Regence MedAdvantage + Rx (PPO)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	803	0	2021	04	Regence MedAdvantage + Rx 02 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5009	804	0	2021	04	Regence MedAdvantage + Rx 03 (PPO)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H5010	001	0	2021	04	Asuris Esteem (PPO)	Spokane and Chelan Counties		Spokane and Chelan Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.asuris.com/medicare	www.asuris.com/medicare	www.asuris.com/medicare
H5010	002	0	2021	04	Asuris TruAdvantage + Rx Classic (PPO)	Spokane and Chelan Counties		Spokane and Chelan Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.asuris.com/medicare	www.asuris.com/medicare	www.asuris.com/medicare
H5010	004	0	2021	04	Asuris TruAdvantage + Rx Enhanced (PPO)	Spokane County		Spokane County	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.asuris.com/medicare	www.asuris.com/medicare	www.asuris.com/medicare
H5010	007	0	2021	04	Asuris TruAdvantage + Rx Primary (PPO)	Spokane and Chelan Counties		Spokane and Chelan Counties	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.asuris.com/medicare	www.asuris.com/medicare	www.asuris.com/medicare
H5015	001	0	2021	01	Texas Independence Health Plan, Inc. (HMO I-SNP)	Texas (Partial)		Texas (Partial)	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.txindependencehealthplan.com	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.txindependencehealthplan.com	www.txindependencehealthplan.com	www.txindependencehealthplan.com
H5037	001	0	2021	20	Mountain Empire PACE - Dual (PACE)	Lee, Scott, Wise Counties and Norton City		Lee, Scott, Wise Counties and Norton City	1	3	0									P. O. Box 888		Big Stone Gap	VA	24219		genia.garrett@meoc.org	genia.garrett@meoc.org	2000000000208301630308301630408301630508301630608301630000000000	2000000000208301630308301630408301630508301630608301630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.meoc.org	0	0	1			0					3	0	0		www.meoc.org	www.meoc.org
H5037	002	0	2021	20	Mountain Empire PACE  - Medicare only (PACE)	Lee, Scott, Wise Counties and Norton City		Lee, Scott, Wise Counties and Norton City	1	3	0									PO Box 888		Big Stone Gap	VA	24219		genia.garrett@meoc.org	genia.garrett@meoc.org	2000000000208301630308301630408301630508301630608301630000000000	2000000000208301630308301630408301630508301630608301630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.meoc.org	0	0	1			0					3	0	0		www.meoc.org	www.meoc.org
H5042	009	0	2021	04	CDPHP Vital Rx (PPO)	Greater Capital Region of New York State	CDPHP Vital Rx (PPO)	Greater Capital Region of New York State	1	0	0	500 patroon creek blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 patroon creek blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cdphp.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cdphp.com	www.cdphp.com	www.cdphp.com
H5042	011	0	2021	04	CDPHP Flex Rx (PPO)	Greater Capital Region of New York State	CDPHP Flex Rx (PPO)	Greater Capital Region of New York State	1	0	0	500 patroon creek blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 patroon creek blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H5042	012	0	2021	04	CDPHP Flex (PPO)	Greater Capital Region of New York State	CDPHP Flex (PPO)	Greater Capital Region of New York State	1	0	0	500 patroon creek blvd		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H5042	801	0	2021	04	CDPHP Group Medicare Rx (PPO)	Greater Capital Region of New York State	CDPHP Group Medicare Rx (PPO)	Greater Capital Region of New York State	1	3	1	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H5042	802	0	2021	04	CDPHP Group Medicare Rx (PPO)	Greater Capital Region of New York State	CDPHP Group Medicare Rx (PPO)	Greater Capital Region of New York State	1	3	1	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H5042	803	0	2021	04	CDPHP Group Medicare (PPO)	Greater Capital Region of New York State	CDPHP Group Medicare (PPO)	Greater Capital Region of New York State	1	3	1	500 Patroon Creek Blvd.		Albany	NY	12206		Medicare_inside_sales@cdphp.com	info@cdphp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.CDPHP.com/medicare	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	http://www.CDPHP.com/medicare	https://www.hometownhealthrx.com/	http://www.cdphp.com/medicare
H5050	001	0	2021	01	Kaiser Permanente Medicare Advantage Basic (HMO)	Puget Sound Area and Counties: GY, TH, LE, SP		Puget Sound Area and Counties: GY, TH, LE, SP	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org										5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	004	0	2021	01	Kaiser Permanente Medicare Advantage Optimal (HMO)	Counties: KI, PI, KP, SN, GY, LE, MA, TH		Counties: KI, PI, KP, SN, GY, LE, MA, TH	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	009	0	2021	01	Kaiser Permanente Medicare Advantage Essential (HMO)	Counties: KI, PI, KP, SN, GY, LE, MA, TH		Counties: KI, PI, KP, SN, GY, LE, MA, TH	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	013	0	2021	01	Kaiser Permanente Medicare Advantage Vital (HMO)	Counties: KI, PI, KP, SN, GY, LE, MA, TH		Counties: KI, PI, KP, SN, GY, LE, MA, TH	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	017	0	2021	01	Kaiser Permanente Medicare Advantage Harbor (HMO)	Counties: IS, SK, WM		Counties: IS, SK, WM	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	019	0	2021	01	Kaiser Permanente Medicare Advantage Columbia (HMO)	Spokane		Spokane	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	021	0	2021	01	Kaiser Permanente Medicare Advantage Centennial (HMO)	Spokane		Spokane	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	022	0	2021	01	Kaiser Permanente Medicare Advantage Key (HMO)	Island,King,Pierce,Snohomish and Thurston counties		Island,King,Pierce,Snohomish and Thurston counties	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	023	0	2021	01	Kaiser Permanente Medicare Advantage Anchor (HMO)	Counties: Skagit, Whatcom		Counties: Skagit, Whatcom	1	0	0	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	801	0	2021	01	Kaiser Permanente Medicare Advantage Group [AB] (HMO)	Puget Sound Area and Counties: GY, TH, LE, SP		Puget Sound Area and Counties: GY, TH, LE, SP	1	3	1	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org										5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5050	802	0	2021	01	Kaiser Permanente Medicare Advantage Group [ABD] (HMO)	Puget Sound Area and Counties: GY, TH, LE, SP		Puget Sound Area and Counties: GY, TH, LE, SP	1	3	1	1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		1300 SW 27th St.		Renton	WA	98057		kpwa.medicare@kp.org		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/wa/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/wa/medicare/providers	kp.org/wa/medicare/providers	kp.org/wa/medicare/formulary
H5085	003	0	2021	20	Community PACE at Home, Inc. - Dual Eligible (PACE)	Lake, Newaygo, Oceana, Osceola, Mason, Mecosta,		Lake, Newaygo, Oceana, Osceola, Mason, Mecosta,	1	3	0									231 West Pine Lake Drive		Newaygo	MI	49337		kwozniak@communitypace.com	kwozniak@communitypace.com	2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.communitypace.com	0	0	1			0					3	0	0		N/A	N/A
H5085	004	0	2021	20	Community PACE at Home, Inc - Medicare Only (PACE)	Lake, Newaygo, Oceana, Osceola, Mason, Mecosta,		Lake, Newaygo, Oceana, Osceola, Mason, Mecosta,	1	3	0									231 West Pine Lake Drive		Newaygo	MI	49337		kwozniak@communitypace.com	kwozniak@communitypace.com	2000000000208001600308001600408001600508001600608001600000000000	2000000000208001600308001600408001600508001600608001600000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.communitypace.com	0	0	1			0					3	0	0		N/A	N/A
H5087	001	0	2021	01	WellCare Freedom (HMO D-SNP)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	002	0	2021	01	WellCare Plus (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	005	0	2021	01	WellCare Best (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	016	0	2021	01	WellCare Best (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	017	0	2021	01	WellCare Plus (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	024	0	2021	01	WellCare Best (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	025	0	2021	01	WellCare Dividend (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5087	026	0	2021	01	WellCare Best (HMO)	Select counties in CA		Select counties in CA	1	0	0	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	PO Box 31685	Attn: Pre Enrollment	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5106	013	0	2021	04	Freedom Blue PPO Standard (PPO)	West Virginia Region 1 counties		West Virginia Region 1 counties	1	0	0	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H5106	029	1	2021	04	Freedom Blue PPO Distinct (PPO)	Region 2 WV Counties		North WV	1	0	0	PO Box 1908	P.O. Box 1068	Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	PO Box 1908	P.O. Box 1068	Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H5106	029	2	2021	04	Freedom Blue PPO Distinct (PPO)	Region 2 WV Counties		South WV	1	0	0	PO Box 1908	P.O. Box 1068	Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	PO Box 1908	P.O. Box 1068	Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H5106	806	0	2021	04	Freedom Blue PPO MAPD WV NON-CALENDAR (PPO)	ALL WV COUNTIES		ALL WV COUNTIES	1	3	1	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H5106	807	0	2021	04	Freedom Blue PPO MA WV Calendar (PPO)	ALL WV COUNTIES		ALL WV COUNTIES	1	3	1	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	2	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H5106	808	0	2021	04	Freedom Blue PPO MAPD WV CALENDAR (PPO)	ALL WV COUNTIES		ALL WV COUNTIES	1	3	1	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	PO Box 1908		Parkersburg	WV	26102		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	0	medicare.highmark.com	medicare.highmark.com	medicare.highmark.com
H5117	003	0	2021	01	Allwell Medicare (HMO)	Baton Rouge, Lafayette & Surrounding Areas		Baton Rouge, Lafayette & Surrounding Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5117	004	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Baton Rouge, North LA & Surrounding Areas		Baton Rouge, North LA & Surrounding Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5117	005	0	2021	01	Allwell Dual Medicare Essentials (HMO D-SNP)	Baton Rouge, North LA & Surrounding Areas		Baton Rouge, North LA & Surrounding Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5117	006	0	2021	01	Allwell Medicare Simple (HMO)	Baton Rouge, Lafayette & Surrounding Areas		Baton Rouge, Lafayette & Surrounding Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5117	801	0	2021	01	Allwell Group (HMO)	Louisiana		Louisiana	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5117	802	0	2021	01	Allwell Group (HMO)	Louisiana		Louisiana	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5117	803	0	2021	01	Allwell Group (HMO)	Louisiana		Louisiana	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.louisianahealthconnect.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/findadoctor	allwell.louisianahealthconnect.com/formulary
H5124	001	0	2021	20	Franciscan Senior Health and Wellness (PACE)	Central and Northern Indiana		Central and Northern Indiana	1	3	0									8325 E. Southport Rd., Ste. 120		Indianapolis	IN	46259		Peggy.Homeier@franciscanalliance.org	Peggy.Homeier@franciscanalliance.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FranciscanStFrancis.org	0	0	1			0					3	0	0		carekinesis.org	franciscanalliance.org
H5124	002	0	2021	20	Franciscan Senior Health and Wellness (PACE)	Central and Northern Indiana		Central and Northern Indiana	1	3	0									8325 E. Southport Rd., Ste. 120		Indianapolis	IN	46259		Peggy.Homeier@franciscanalliance.org	Peggy.Homeier@franciscanalliance.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FranciscanStFrancis.org	0	0	1			0					3	0	0		carekinesis.org	franciscanalliance.org
H5126	001	0	2021	01	Oscar Easy Care (HMO)	Harris, Fort Bend, and Montgomery Counties		Harris, Fort Bend, and Montgomery Counties	1	0	0	PO Box 62045		Phoenix	AZ	85082				PO Box 62045		Phoenix	AZ	85082				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hioscar.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.hioscar.com/search	www.hioscar.com/search	www.hioscar.com/search
H5140	001	0	2021	04	BlueJourney (PPO)	Maricopa County		Maricopa County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H5140	002	0	2021	04	BlueJourney (PPO)	Pima County		Pima County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H5141	001	0	2021	04	Clover Health Choice (PPO)	Hudson County		Hudson County	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	004	0	2021	04	Clover Health Choice (PPO)	Select NJ Counties		Select NJ Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	007	0	2021	04	Clover Health Choice Value (PPO)	Select NJ Counties		Select NJ Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	025	0	2021	04	Clover Health Choice (PPO)	Bexar County		Bexar County	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	026	0	2021	04	Clover Health Choice (PPO)	Select GA Counties		Select GA Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	032	0	2021	04	Clover Health Choice (PPO)	Select NJ Counties		Select NJ Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	033	0	2021	04	Clover Health Choice (PPO)	Davidson, Rutherford & Williamson Counties		Davidson, Rutherford & Williamson Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	034	0	2021	04	Clover Health Choice Value (PPO)	Davidson, Rutherford & Williamson Counties		Davidson, Rutherford & Williamson Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	035	0	2021	04	Clover Health Choice (PPO)	El Paso County		El Paso County	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	036	0	2021	04	Clover Health Choice (PPO)	Select SC Counties		Select SC Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	037	0	2021	04	Clover Health Choice Value (PPO)	Select SC Counties		Select SC Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	038	0	2021	04	Clover Health Choice (PPO)	Bucks, Philadelphia & Delaware Counties		Bucks, Philadelphia & Delaware Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	039	0	2021	04	Clover Health Choice Value (PPO)	Bucks, Philadelphia & Delaware Counties		Bucks, Philadelphia & Delaware Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	040	0	2021	04	Clover Health Choice (PPO)	Pima County		Pima County	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	042	0	2021	04	Clover Health Choice Value (PPO)	Select NJ Counties		Select NJ Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	045	0	2021	04	Clover Health Choice Value (PPO)	Select Counties in GA		Select Counties in GA	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com	www.cloverhealth.com	www.cloverhealth.com
H5141	046	0	2021	04	Clover Health Choice (PPO)	Atlanta, Macon, and rural areas		Atlanta, Macon, and rural areas	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5141	047	0	2021	04	Clover Health Choice Value (PPO)	Atlanta, Macon, and rural areas		Atlanta, Macon, and rural areas	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com	www.cloverhealth.com	www.cloverhealth.com
H5141	048	0	2021	04	LiveHealthy: Clover Powered, Walmart Enhanced (PPO)	Select Counties in GA		Select Counties in GA	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	1	www.cloverhealth.com	www.cloverhealth.com	www.cloverhealth.com
H5141	049	0	2021	04	LiveHealthy LI: Clover Powered, Walmart Enhanced (PPO)	Select Counties in GA		Select Counties in GA	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com	www.cloverhealth.com	www.cloverhealth.com
H5141	050	0	2021	04	Clover Health Choice (PPO)	Jackson and rural areas		Jackson and rural areas	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	1	www.cloverhealth.com	www.cloverhealth.com	www.cloverhealth.com
H5141	051	0	2021	04	Clover Health Choice Value (PPO)	Jackson and rural areas		Jackson and rural areas	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com	www.cloverhealth.com	www.cloverhealth.com
H5141	801	0	2021	04	Clover Health Employer Group Plan (PPO)	Select NJ & PA Counties		Select NJ & PA Counties	1	3	1	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H5167	001	0	2021	20	Rocky Mountain PACE (PACE)	Colorado Springs Metro Area		Colorado Springs Metro Area	1	3	0									2502 E Pikes Peak		Colorado Springs	CO	80909		sgalceran@rmhcare.org	amcdonough@rmhcare.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	rmhcare.org	0	0	1			0					3	0	0		www.rmhcare.org	www.rmhcare.org
H5167	002	0	2021	20	Rocky Mountain PACE (PACE)	Colorado Springs Metro Area		Colorado Springs Metro Area	1	3	0									2502 E Pikes Peak		Colorado Springs	CO	80909		sgalceran@rmhcare.org	amcdonough@rmhcare.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	rmhcare.org	0	0	1			0					3	0	0		www.rmhcare.org	www.rmhcare.org
H5172	002	0	2021	48	CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan)	San Diego, California		San Diego, California	1	0	0	2420 Fenton Street, Suite 100		Chula Vista	CA	91914				2420 Fenton Street, Suite 100		Chula Vista	CA	91914				5106002000206002000306002000406002000506002000606002000706002000	5106002000206002000306002000406002000506002000606002000706002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.chgsd.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.chgsd.com	http://www.chgsd.com/	www.chgsd.com
H5178	001	0	2021	01	Humana Gold Plus H5178-001 (HMO)	Greenville County		Greenville County	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5190	001	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Duval and Volusia Counties		Duval and Volusia Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H5190	002	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Counties: HIL, ORA, OSC, PAL, PAS, PIN, POL, SEM		Counties: HIL, ORA, OSC, PAL, PAS, PIN, POL, SEM	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H5190	003	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Broward County		Broward County	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H5190	004	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H5190	005	0	2021	01	Allwell Medicare Nurture (HMO D-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H5190	006	0	2021	01	Allwell Medicare Nurture (HMO D-SNP)	Miami-Dade County		Miami-Dade County	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H5199	007	0	2021	04	WellCare Premier (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5199	008	0	2021	04	WellCare Premier (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5199	010	0	2021	04	WellCare Prime (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5199	012	0	2021	04	WellCare Premier (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5199	013	0	2021	04	WellCare Prime (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5199	014	0	2021	04	WellCare Premier (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5199	015	0	2021	04	WellCare Premier (PPO)	Select counties in FL		Select counties in FL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5209	002	0	2021	01	My Choice Wisconsin Partnership Plan (HMO D-SNP)	Southcentral and Eastern Wisconsin		Southcentral and Eastern Wisconsin	1	0	0	Care Wisconsin Health Plan, Inc.	1617 Sherman Ave.	Madison	WI	53704				Care Wisconsin Health Plan, Inc.	1617 Sherman Ave.	Madison	WI	53704				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.mychoicewi.org	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mychoicewi.org	www.mychoicewi.org	www.mychoicewi.org
H5209	004	0	2021	01	My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP)	Southern, Central and Northeastern Wisconsin		Southern, Central and Northeastern Wisconsin	1	0	0	Care Wisconsin Health Plan, Inc.	1617 Sherman Ave.	Madison	WI	53704				Care Wisconsin Health Plan, Inc.	1617 Sherman Ave.	Madison	WI	53704				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mychoicewi.org	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mychoicewi.org	www.mychoicewi.org	www.mychoicewi.org
H5211	001	0	2021	02	Spirit (HMO-POS)	Central, Northern, Western and South Central WI		Central, Northern, Western and South Central WI	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	002	0	2021	02	Essence Rx (HMO-POS)	Central, Northern, Western and South Central WI		Central, Northern, Western and South Central WI	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	003	0	2021	02	Essence (HMO-POS)	Central, Northern, Western and South Central WI		Central, Northern, Western and South Central WI	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	004	0	2021	02	Spirit Rx (HMO-POS)	Central, Northern, Western and South Central WI		Central, Northern, Western and South Central WI	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	007	0	2021	02	Assurance Rx (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	008	0	2021	02	Surety Rx (HMO-POS)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.securityhealth.org/providersmedicare	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	009	0	2021	02	Promise Rx (HMO-POS)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $270.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $270.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.securityhealth.org/providersmedicare	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	010	0	2021	01	Ally Rx (HMO D-SNP)	Central Wisconsin		Central Wisconsin	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.securityhealth.org/medicareadvantage	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.securityhealth.org/allyproviders	www.securityhealth.org/allypharmacies	www.securityhealth.org/allyformulary
H5211	012	0	2021	02	Esteem Rx (HMO-POS)	Central, Northern, Western WI		Central, Northern, Western WI	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5211	013	0	2021	02	Ascend Rx (HMO-POS)	Central, Northern, Western and South Central WI		Central, Northern, Western and South Central WI	1	0	0	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	1515 North Saint Joseph Avenue	PO Box 8000	Marshfield	WI	54449		shpsalessupport@securityhealth.org	shpcsweb@securityhealth.org	3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.securityhealth.org/medicareadvantage	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.securityhealth.org/medicareproviders	www.securityhealth.org/medicarepharmacies	www.securityhealth.org/medicareformulary
H5212	001	0	2021	20	Community Care's PACE Program (PACE)	Milwaukee County, Waukesha County, Racine County		Milwaukee County, Waukesha County, Racine County	1	3	0									205 Bishops Way		Brookfield	WI	53005				3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.communitycareinc.org	0	0	1			0					3	0	0	www.communitycareinc.org	www.communitycareinc.org	www.communitycareinc.org
H5212	002	0	2021	20	Community Care's PACE Program (PACE)	Milwaukee County, Waukesha County, Racine County		Milwaukee County, Waukesha County, Racine County	1	3	0									205 Bishops Way		Brookfield	WI	53005				3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.communitycareinc.org	0	0	1			0					3	0	0	www.communitycareinc.org	www.communitycareinc.org	www.communitycareinc.org
H5213	001	0	2021	20	Total Community Care (PACE)	Albuquerque Metro Area		Albuquerque Metro Area	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	4000000000207301730307301730407301730507301730607301730000000000	4000000000207301730307301730407301730507301730607301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		www.granerx.com	N/A
H5213	002	0	2021	20	Total Community Care (PACE)	Albuquerque Metro Area		Albuquerque Metro Area	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	4000000000207301730307301730407301730507301730607301730000000000	4000000000207301730307301730407301730507301730607301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.myinnovage.com	0	0	1			0					3	0	0		www.granerx.com	N/A
H5215	001	0	2021	04	Network PlatinumPlus (PPO)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	002	0	2021	04	Network PlatinumPlus Pharmacy (PPO)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	005	0	2021	04	Network PlatinumPremier Pharmacy (PPO)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	006	0	2021	04	Network PlatinumPremier (PPO)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	007	0	2021	04	NetworkCares (PPO D-SNP)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	008	0	2021	04	Network PlatinumSelect (PPO)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	009	0	2021	04	Network Health Medicare Go (PPO)	Southeast Wisconsin		Southeast Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	010	0	2021	04	Network Health Medicare Anywhere (PPO)	Southeast Wisconsin		Southeast Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	011	0	2021	04	Network PlatinumChoice (PPO)	East Central Wisconsin		East Central Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	806	0	2021	04	Network PlatinumPlus Pharmacy EGP (PPO)	Wisconsin		Wisconsin	1	3	1	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	807	0	2021	04	Network PlatinumPremier EGP (PPO)	Wisconsin		Wisconsin	1	3	1	1570 Midway Place	P.O. Box 120	Menasha	WI	54952												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5215	808	0	2021	04	Network PlatinumPremier Pharmacy EGP (PPO)	Wisconsin		Wisconsin	1	3	1	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5216	001	0	2021	04	HumanaChoice H5216-001 (PPO)	Select Counties in Eastern Wisconsin		Select Counties in Eastern Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	006	0	2021	04	HumanaChoice H5216-006 (PPO)	Madison area		Madison area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	009	0	2021	04	HumanaChoice H5216-009 (PPO)	Select Counties in Western Michigan		Select Counties in Western Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	011	0	2021	04	HumanaChoice H5216-011 (PPO)	Oakland, Macomb, and Wayne counties		Oakland, Macomb, and Wayne counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	013	0	2021	04	HumanaChoice H5216-013 (PPO)	Select Counties in Illinois		Select Counties in Illinois	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	014	0	2021	04	HumanaChoice H5216-014 (PPO)	Select Counties in Iowa and Nebraska		Select Counties in Iowa and Nebraska	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	017	0	2021	04	HumanaChoice H5216-017 (PPO)	Greensboro		Greensboro	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	018	0	2021	04	HumanaChoice H5216-018 (PPO)	Louisville Metro Area		Louisville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	019	0	2021	04	HumanaChoice H5216-019 (PPO)	Lexington Metro Area		Lexington Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	021	0	2021	04	HumanaChoice H5216-021 (PPO)	Charleston-Huntington Metro Area		Charleston-Huntington Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	022	0	2021	04	HumanaChoice H5216-022 (PPO)	Martinsburg Metro Area		Martinsburg Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	023	0	2021	04	HumanaChoice H5216-023 (PPO)	Cincinnati, Dayton and Columbus Metro Areas		Cincinnati, Dayton and Columbus Metro Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	024	0	2021	04	HumanaChoice H5216-024 (PPO)	Cleveland-Akron Metro Areas		Cleveland-Akron Metro Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	027	0	2021	04	HumanaChoice H5216-027 (PPO)	Northeast Virginia		Northeast Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $215.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $215.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	028	0	2021	04	HumanaChoice H5216-028 (PPO)	Kent, New Castle and Sussex Counties		Kent, New Castle and Sussex Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	029	0	2021	04	HumanaChoice H5216-029 (PPO)	Select Counties in Western Maryland		Select Counties in Western Maryland	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	032	0	2021	04	HumanaChoice H5216-032 (PPO)	Select Counties in Illinois, Kansas and Missouri		Select Counties in Illinois, Kansas and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	033	1	2021	04	HumanaChoice H5216-033 (PPO)	Select Counties in Illinois, Kansas, and Missouri		Select Counties in Kansas and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	033	2	2021	04	HumanaChoice H5216-033 (PPO)	Select Counties in Illinois, Kansas, and Missouri		Select Counties in Illinois and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	034	0	2021	04	HumanaChoice H5216-034 (PPO)	Select Counties in Arizona		Select Counties in Arizona	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	036	0	2021	04	HumanaChoice H5216-036 (PPO)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	037	0	2021	04	HumanaChoice H5216-037 (PPO)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	039	0	2021	04	HumanaChoice H5216-039 (PPO)	Washoe County		Washoe County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	042	0	2021	04	HumanaChoice H5216-042 (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	043	1	2021	04	HumanaChoice H5216-043 (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	043	2	2021	04	HumanaChoice H5216-043 (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	044	0	2021	04	HumanaChoice H5216-044 (PPO)	Select counties in Idaho and Oregon		Select counties in Idaho and Oregon	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	046	0	2021	04	Humana Honor (PPO)	Select Counties in ID, OR, WA and UT		Select Counties in ID, OR, WA and UT	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	047	0	2021	04	HumanaChoice H5216-047 (PPO)	Select Counties in Washington and Oregon		Select Counties in Washington and Oregon	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	048	0	2021	04	HumanaChoice H5216-048 (PPO)	Select counties in OR and WA		Select counties in OR and WA	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	050	0	2021	04	HumanaChoice H5216-050 (PPO)	Northwest Ohio Area		Northwest Ohio Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	051	0	2021	04	HumanaChoice H5216-051 (PPO)	Canton-Youngstown Metro Area		Canton-Youngstown Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	052	1	2021	04	HumanaChoice H5216-052 (PPO)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	052	2	2021	04	HumanaChoice H5216-052 (PPO)	Select counties in Ohio		Select counties in northwest West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	053	0	2021	04	HumanaChoice H5216-053 (PPO)	Central Indiana Area		Central Indiana Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	054	0	2021	04	HumanaChoice H5216-054 (PPO)	Southern Indiana Area		Southern Indiana Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	055	0	2021	04	HumanaChoice H5216-055 (PPO)	Northern Indiana Area		Northern Indiana Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	057	0	2021	04	HumanaChoice H5216-057 (PPO)	New Hampshire and Select Counties in Vermont		New Hampshire and Select Counties in Vermont	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	058	0	2021	04	HumanaChoice H5216-058 (PPO)	New Hampshire and Select Counties in Vermont		New Hampshire and Select Counties in Vermont	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	059	0	2021	04	Humana Honor (PPO)	Select Counties in New England		Select Counties in New England	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	061	0	2021	04	HumanaChoice Florida H5216-061 (PPO)	Select Counties in Florida		Select Counties in Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	062	0	2021	04	HumanaChoice Florida H5216-062 (PPO)	Select Counties in Florida		Select Counties in Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	063	0	2021	04	HumanaChoice H5216-063 (PPO)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	064	0	2021	04	HumanaChoice H5216-064 (PPO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 W Main St		Louisville	KY	40202				500 W Main St		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	065	0	2021	04	HumanaChoice H5216-065 (PPO)	Broward, Miami-Dade and Palm Beach Counties		Broward, Miami-Dade and Palm Beach Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	068	0	2021	04	HumanaChoice Florida H5216-068 (PPO)	Broward, Miami-Dade and Palm Beach Counties		Broward, Miami-Dade and Palm Beach Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	070	0	2021	04	HumanaChoice Florida H5216-070 (PPO)	Select Counties in Florida		Select Counties in Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	071	0	2021	04	HumanaChoice H5216-071 (PPO)	Cobb, Paulding, Douglas Counties		Cobb, Paulding, Douglas Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	072	0	2021	04	HumanaChoice Florida H5216-072 (PPO)	Select Counties in Florida		Select Counties in Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	073	0	2021	04	HumanaChoice H5216-073 (PPO)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	074	0	2021	04	HumanaChoice Florida H5216-074 (PPO)	Lake, Marion and Sumter counties		Lake, Marion and Sumter counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	075	0	2021	04	HumanaChoice H5216-075 (PPO)	Charleston Metro Area		Charleston Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	077	0	2021	04	HumanaChoice H5216-077 (PPO)	Select Counties in Colorado and New Mexico		Select Counties in Colorado and New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	078	1	2021	04	HumanaChoice H5216-078 (PPO)	Select Counties in Colorado		Select Counties in Colorado	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	078	2	2021	04	HumanaChoice H5216-078 (PPO)	Select Counties in Colorado		Colorado Springs/Grand Junction/Durango	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	080	1	2021	04	HumanaChoice H5216-080 (PPO)	Twin Cities, Rochester, Duluth Areas		Twin Cities, Rochester, Duluth Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	080	2	2021	04	HumanaChoice H5216-080 (PPO)	Twin Cities, Rochester, Duluth Areas		Twin Cities, Rochester, Duluth Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	080	3	2021	04	HumanaChoice H5216-080 (PPO)	Twin Cities, Rochester, Duluth Areas		Twin Cities, Rochester, Duluth Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	081	0	2021	04	HumanaChoice H5216-081 (PPO)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	083	0	2021	04	HumanaChoice H5216-083 (PPO)	Select Counties in AR, KS, MO, and OK		Select Counties in AR, KS, MO, and OK	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	086	0	2021	04	Humana Honor (PPO)	Select Counties in IA, MN, MT, ND, NE, SD		Select Counties in IA, MN, MT, ND, NE, SD	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	088	0	2021	04	HumanaChoice H5216-088 (PPO)	Select Counties in North and South Dakota		Select Counties in North and South Dakota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	089	0	2021	04	HumanaChoice H5216-089 (PPO)	Select Counties in Montana		Select Counties in Montana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	092	0	2021	04	HumanaChoice H5216-092 (PPO)	Select Counties in MN, ND and SD		Select Counties in MN, ND and SD	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	093	0	2021	04	HumanaChoice H5216-093 (PPO)	Memphis Metro Area		Memphis Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	096	0	2021	04	HumanaChoice H5216-096 (PPO)	Dothan Metro Area		Dothan Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	097	0	2021	04	HumanaChoice H5216-097 (PPO)	Nashville Metro Area		Nashville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	098	0	2021	04	HumanaChoice H5216-098 (PPO)	Chattanooga Metro Area		Chattanooga Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	099	0	2021	04	HumanaChoice H5216-099 (PPO)	Knoxville Metro Area		Knoxville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	100	0	2021	04	HumanaChoice H5216-100 (PPO)	Select Counties in the Tri-Cities Area of Virginia		Select Counties in the Tri-Cities Area of Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	103	0	2021	04	HumanaChoice H5216-103 (PPO)	Select Counties in North Dakota and South Dakota		Select Counties in North Dakota and South Dakota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	105	0	2021	04	HumanaChoice H5216-105 (PPO)	Kentucky and West Virginia		Kentucky and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	106	0	2021	04	HumanaChoice H5216-106 (PPO)	Select counties in Northeast Ohio		Select counties in Northeast Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	107	0	2021	04	HumanaChoice H5216-107 (PPO)	Select counties in Kentucky		Select counties in Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	109	0	2021	04	HumanaChoice H5216-109 (PPO)	Ohio		Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	111	0	2021	04	HumanaChoice H5216-111 (PPO)	Select Counties in Indiana and Kentucky		Select Counties in Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	112	0	2021	04	HumanaChoice H5216-112 (PPO)	Select counties in Northeast and Fort Wayne IN		Select counties in Northeast and Fort Wayne IN	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	114	0	2021	04	HumanaChoice H5216-114 (PPO)	Select counties in Indianapolis		Select counties in Indianapolis	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	115	0	2021	04	Humana Value Plus H5216-115 (PPO)	Select counties in Kentucky		Select counties in Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $425.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $425.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	116	0	2021	04	HumanaChoice H5216-116 (PPO)	Select Counties in Pennsylvania and New Jersey		Select Counties in Pennsylvania and New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	117	0	2021	04	Humana Value Plus H5216-117 (PPO)	Greater Pittsburgh Area		Greater Pittsburgh Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	120	0	2021	04	HumanaChoice H5216-120 (PPO)	South Central Pennsylvania Area		South Central Pennsylvania Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	124	0	2021	04	HumanaChoice H5216-124 (PPO)	Select counties in West Virginia		Select counties in West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	125	0	2021	04	Humana Value Plus H5216-125 (PPO)	Select counties in West Virginia		Select counties in West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	127	0	2021	04	Humana Honor (PPO)	Kent, New Castle and Sussex Counties		Kent, New Castle and Sussex Counties	1	0	0	500 West Main Street		Louisville	KY	40202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	128	0	2021	04	Humana Honor (PPO)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	129	0	2021	04	Humana Honor (PPO)	Select Counties in Western Maryland		Select Counties in Western Maryland	1	0	0	500 West Main Street		Louisville	KY	40202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	131	0	2021	04	HumanaChoice H5216-131 (PPO)	Davis, Salt Lake, Utah and Weber Counties		Davis, Salt Lake, Utah and Weber Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	132	0	2021	04	HumanaChoice H5216-132 (PPO)	Select Counties in Idaho and Malheur County Oregon		Select Counties in Idaho and Malheur County Oregon	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	133	0	2021	04	HumanaChoice H5216-133 (PPO)	Macomb, Oakland and Wayne counties		Macomb, Oakland and Wayne counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	136	0	2021	04	HumanaChoice H5216-136 (PPO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	137	0	2021	04	HumanaChoice H5216-137 (PPO)	Select Counties in New Mexico and Colorado		Select Counties in New Mexico and Colorado	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	138	0	2021	04	HumanaChoice H5216-138 (PPO)	Select Counties in New England		Select Counties in New England	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	139	0	2021	04	HumanaChoice H5216-139 (PPO)	Select Counties in Arkansas and Oklahoma		Select Counties in Arkansas and Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	140	0	2021	04	Humana Honor (PPO)	Select Counties in AR, IL, KS, MO, and OK		Select Counties in AR, IL, KS, MO, and OK	1	0	0	500 West Main Street		Louisville	KY	40202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	141	0	2021	04	HumanaChoice H5216-141 (PPO)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $365.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $365.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	142	1	2021	04	HumanaChoice H5216-142 (PPO)	Select Counties in Georgia and South Carolina		Columbia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	142	2	2021	04	HumanaChoice H5216-142 (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	143	0	2021	04	HumanaChoice H5216-143 (PPO)	Barrow, Hall, Jackson Counties		Barrow, Hall, Jackson Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	144	0	2021	04	HumanaChoice H5216-144 (PPO)	Richmond-Tidewater Area		Richmond-Tidewater Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	149	0	2021	04	HumanaChoice H5216-149 (PPO)	Lynchburg - Winchester Area		Lynchburg - Winchester Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	152	0	2021	04	HumanaChoice H5216-152 (PPO)	Virginia		Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	154	0	2021	04	HumanaChoice H5216-154 (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	157	0	2021	04	HumanaChoice H5216-157 (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	158	0	2021	04	HumanaChoice H5216-158 (PPO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	160	0	2021	04	Humana Value Plus H5216-160 (PPO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	161	0	2021	04	Humana Value Plus H5216-161 (PPO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $425.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $425.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	163	0	2021	04	HumanaChoice H5216-163 (PPO)	Select Counties in Arkansas, Kansas and Missouri		Select Counties in Arkansas, Kansas and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	164	0	2021	04	HumanaChoice SNP-DE H5216-164 (PPO D-SNP)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	165	0	2021	04	Humana Value Plus H5216-165 (PPO)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	166	0	2021	04	Humana Value Plus H5216-166 (PPO)	Select Counties in Kansas		Select Counties in Kansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	167	0	2021	04	HumanaChoice H5216-167 (PPO)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	168	0	2021	04	HumanaChoice H5216-168 (PPO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	169	0	2021	04	HumanaChoice H5216-169 (PPO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	170	0	2021	04	HumanaChoice H5216-170 (PPO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	171	0	2021	04	Humana Value Plus H5216-171 (PPO)	Select Counties in IA, NE, ND, and SD		Select Counties in IA, NE, ND, and SD	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $305.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $305.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	172	0	2021	04	HumanaChoice H5216-172 (PPO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	173	0	2021	04	Humana Value Plus H5216-173 (PPO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $230.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $230.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	174	0	2021	04	Humana Honor (PPO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	175	0	2021	04	HumanaChoice H5216-175 (PPO)	Maine		Maine	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	176	0	2021	04	Humana Value Plus H5216-176 (PPO)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $230.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $230.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	177	0	2021	04	HumanaChoice H5216-177 (PPO)	Maine		Maine	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	179	0	2021	04	HumanaChoice H5216-179 (PPO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	180	0	2021	04	HumanaChoice H5216-180 (PPO)	Select Counties in TN		Select Counties in TN	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	181	0	2021	04	HumanaChoice H5216-181 (PPO)	Select VA Counties in the Tri-Cities Area		Select VA Counties in the Tri-Cities Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	182	0	2021	04	HumanaChoice H5216-182 (PPO)	West Virginia		West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	185	0	2021	04	HumanaChoice H5216-185 (PPO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	186	0	2021	04	HumanaChoice H5216-186 (PPO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	188	0	2021	04	HumanaChoice H5216-188 (PPO)	Select Counties in Indiana and Kentucky		Select Counties in Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	189	0	2021	04	HumanaChoice H5216-189 (PPO)	Iron and Washington counties		Iron and Washington counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	190	0	2021	04	Humana Honor (PPO)	Select counties in Michigan		Select counties in Michigan	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	192	0	2021	04	HumanaChoice H5216-192 (PPO)	Select counties in Indiana		Select counties in Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	193	0	2021	04	Humana Value Plus H5216-193 (PPO)	Select counties in Indiana		Select counties in Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	194	0	2021	04	HumanaChoice H5216-194 (PPO)	Washoe County		Washoe County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $365.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $365.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	195	0	2021	04	Humana Value Plus H5216-195 (PPO)	Colorado		Colorado	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	196	1	2021	04	HumanaChoice H5216-196 (PPO)	New Mexico		Southern New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	196	2	2021	04	HumanaChoice H5216-196 (PPO)	New Mexico		Greater New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	197	0	2021	04	Humana Value Plus H5216-197 (PPO)	Select counties in Arizona		Select counties in Arizona	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	198	0	2021	04	HumanaChoice H5216-198 (PPO)	Select Counties in Arizona		Select Counties in Arizona	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	199	0	2021	04	Humana Value Plus H5216-199 (PPO)	Select counties in New Mexico		Select counties in New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	200	0	2021	04	Humana Honor (PPO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 W. Main Street		Louisville	KY	40202												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	201	0	2021	04	Humana Honor (PPO)	Select Counties in Louisiana		Select Counties in Louisiana	1	0	0	500 W. Main Street		Louisville	KY	40202												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	202	0	2021	04	HumanaChoice H5216-202 (PPO)	Select Counties in Louisiana		Select Counties in Louisiana	1	0	0	500 W. Main Street		Louisville	KY	40202				500 W. Main Street		Louisville	KY	40202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	203	1	2021	04	HumanaChoice H5216-203 (PPO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	203	2	2021	04	HumanaChoice H5216-203 (PPO)	Select Counties in Georgia		Macon and Albany Area	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	205	0	2021	04	HumanaChoice SNP-DE H5216-205 (PPO D-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	206	0	2021	04	HumanaChoice SNP-DE H5216-206 (PPO D-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	207	0	2021	04	HumanaChoice H5216-207 (PPO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	209	0	2021	04	HumanaChoice H5216-209 (PPO)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	210	0	2021	04	HumanaChoice H5216-210 (PPO)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	211	0	2021	04	HumanaChoice H5216-211 (PPO)	North Carolina		North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	212	0	2021	04	HumanaChoice H5216-212 (PPO)	Dothan Metro Area		Dothan Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	213	0	2021	04	Humana Honor (PPO)	Select Counties in Arizona, Colorado, New Mexico		Select Counties in Arizona, Colorado, New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	214	1	2021	04	HumanaChoice H5216-214 (PPO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	214	2	2021	04	HumanaChoice H5216-214 (PPO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	214	3	2021	04	HumanaChoice H5216-214 (PPO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	215	0	2021	04	HumanaChoice H5216-215 (PPO)	Select Counties in Illinois		Select Counties in Illinois	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	216	0	2021	04	Humana Honor (PPO)	Clark, Nye (partial) and Washoe counties		Clark, Nye (partial) and Washoe counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	217	0	2021	04	Humana Honor (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	218	0	2021	04	Humana Honor (PPO)	States of Indiana and Ohio		States of Indiana and Ohio	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	219	0	2021	04	HumanaChoice SNP-DE H5216-219 (PPO D-SNP)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	220	0	2021	04	HumanaChoice SNP-DE H5216-220 (PPO D-SNP)	Select Counties in West Virgina		Select Counties in West Virgina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	221	0	2021	04	Humana Honor (PPO)	Select Counties in Pennsylvania and New Jersey		Select Counties in Pennsylvania and New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	222	0	2021	04	HumanaChoice H5216-222 (PPO)	Bannock, Bingham and Bonneville counties		Bannock, Bingham and Bonneville counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	223	0	2021	04	HumanaChoice H5216-223 (PPO)	Greater Colorado		Greater Colorado	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	224	0	2021	04	HumanaChoice H5216-224 (PPO)	Southern Arizona		Southern Arizona	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	225	0	2021	04	Humana Honor (PPO)	Kentucky and West Virginia		Kentucky and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	226	0	2021	04	HumanaChoice H5216-226 (PPO)	Eastern Kentucky		Eastern Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	227	0	2021	04	HumanaChoice SNP-DE H5216-227 (PPO D-SNP)	Select Counties in Pennsylvania		Select Counties in Pennsylvania	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	228	0	2021	04	HumanaChoice SNP-DE H5216-228 (PPO D-SNP)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	229	0	2021	04	HumanaChoice H5216-229 (PPO)	Northwest Indiana		Northwest Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	230	0	2021	04	HumanaChoice H5216-230 (PPO)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	231	0	2021	04	HumanaChoice H5216-231 (PPO)	Northwest Arkansas		Northwest Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	232	1	2021	04	HumanaChoice H5216-232 (PPO)	Honolulu, Kauai and Maui counties		Honolulu County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	232	2	2021	04	HumanaChoice H5216-232 (PPO)	Honolulu, Kauai and Maui counties		Kauai and Maui counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	233	1	2021	04	HumanaChoice H5216-233 (PPO)	Honolulu, Kauai and Maui counties		Honolulu County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	233	2	2021	04	HumanaChoice H5216-233 (PPO)	Honolulu, Kauai and Maui counties		Kauai and Maui counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	234	0	2021	04	Humana Honor (PPO)	Honolulu County		Honolulu County	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	235	0	2021	04	Humana Honor (PPO)	Greater Tennessee		Greater Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	236	0	2021	04	Humana Honor (PPO)	Greater Alabama		Greater Alabama	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	237	1	2021	04	HumanaChoice H5216-237 (PPO)	Upstate South Carolina		Upstate South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	237	2	2021	04	HumanaChoice H5216-237 (PPO)	Upstate South Carolina		Upstate South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	238	1	2021	04	HumanaChoice H5216-238 (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	238	2	2021	04	HumanaChoice H5216-238 (PPO)	Select Counties in Georgia and South Carolina		Charleston Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	239	0	2021	04	Humana Care Extra (PPO)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	240	0	2021	04	Humana Care Extra (PPO D-SNP)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	241	0	2021	04	HumanaChoice H5216-241 (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	242	0	2021	04	Humana Together in Health (PPO I-SNP)	Atlanta Metro Area		Atlanta Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	243	0	2021	04	Humana Together in Health (PPO I-SNP)	Upstate South Carolina		Upstate South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	1	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	244	0	2021	04	HumanaChoice - Diabetes (PPO C-SNP)	South Carolina		South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $145.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $145.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	245	0	2021	04	HumanaChoice - Diabetes and Heart (PPO C-SNP)	South Carolina		South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	246	0	2021	04	HumanaChoice - Diabetes (PPO C-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $145.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $145.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	247	0	2021	04	HumanaChoice H5216-247 (PPO)	Select counties in OR, UT and WA		Select counties in OR, UT and WA	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	248	1	2021	04	HumanaChoice H5216-248 (PPO)	Virginia		Winchester/Fredericksburg	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	248	2	2021	04	HumanaChoice H5216-248 (PPO)	Virginia		Central Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	249	0	2021	04	HumanaChoice H5216-249 (PPO)	Select Counties in Massachusetts		Select Counties in Massachusetts	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	250	0	2021	04	HumanaChoice H5216-250 (PPO)	Select Counties in Massachusetts		Select Counties in Massachusetts	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	251	0	2021	04	HumanaChoice H5216-251 (PPO)	Select Counties in Illinois		Select Counties in Illinois	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	252	0	2021	04	HumanaChoice H5216-252 (PPO)	Select Counties in Eastern Wisconsin		Select Counties in Eastern Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	253	0	2021	04	HumanaChoice H5216-253 (PPO)	Select Counties in Eastern Wisconsin		Select Counties in Eastern Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	254	0	2021	04	HumanaChoice H5216-254 (PPO)	Select Counties in Iowa and Nebraska		Select Counties in Iowa and Nebraska	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	255	0	2021	04	HumanaChoice H5216-255 (PPO)	Select Counties in Montana		Select Counties in Montana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	256	0	2021	04	Humana Honor (PPO)	St. Lucie, Brevard, Indian River, Martin counties		St. Lucie, Brevard, Indian River, Martin counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	257	0	2021	04	Humana Honor (PPO)	Rural Jacksonville		Rural Jacksonville	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	258	0	2021	04	Humana Honor (PPO)	Select Counties in IL, WI		Select Counties in IL, WI	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	805	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	806	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	808	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	809	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	811	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	812	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	813	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	814	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	815	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5216	816	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5232	001	0	2021	04	Paramount Elite - Preferred PPO (PPO)	Paramount Elite Preferred PPO (Northwestern Ohio)		Paramount Elite Preferred PPO (Northwestern Ohio)	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.paramounthealthcare.com/medicareplans	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
H5253	004	0	2021	02	AARP Medicare Advantage (HMO-POS)	Milwaukee Metro area		Milwaukee Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	007	0	2021	02	UnitedHealthcare Nursing Home Plan 1 (HMO-POS I-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	011	0	2021	02	AARP Medicare Advantage (HMO-POS)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	021	0	2021	02	AARP Medicare Advantage Patriot Plan 2 (HMO-POS)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	024	0	2021	01	UnitedHealthcare Dual Complete LP (HMO D-SNP)	Select counties in Wisconsin		Select counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5253	030	0	2021	02	AARP Medicare Advantage (HMO-POS)	Southern Wisconsin		Southern Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	033	0	2021	02	AARP Medicare Advantage Value (HMO-POS)	Milwaukee Metro area		Milwaukee Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	034	0	2021	02	AARP Medicare Advantage Value (HMO-POS)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	035	0	2021	02	AARP Medicare Advantage Plus (HMO-POS)	Graham, Pima, and Santa Cruz counties		Graham, Pima, and Santa Cruz counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	036	0	2021	01	AARP Medicare Advantage (HMO)	Yavapai county		Yavapai county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	037	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Select counties in North Carolina		Select counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	038	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Select counties in North Carolina		Select counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	039	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Durham and Wake counties		Durham and Wake counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $170.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $170.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	040	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	Select counties in North Carolina		Select counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	041	0	2021	02	UnitedHealthcare Dual Complete (HMO-POS D-SNP)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCCommunityPlan.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5253	042	0	2021	02	UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	043	0	2021	02	UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	047	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Select Counties in Tennessee and Virginia		Select Counties in Tennessee and Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	048	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select Counties in Tennessee and Virginia		Select Counties in Tennessee and Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	049	0	2021	01	AARP Medicare Advantage Plan 7 (HMO)	Cleveland Metro area		Cleveland Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	050	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Cleveland Metro area		Cleveland Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	051	0	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Cleveland Metro area		Cleveland Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	052	0	2021	01	AARP Medicare Advantage Plan 6 (HMO)	Cincinnati/Dayton Metro area		Cincinnati/Dayton Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	059	0	2021	01	UnitedHealthcare Dual Complete LP (HMO D-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5253	060	0	2021	02	UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	061	0	2021	02	UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP)	Lake, Lorain, and Lucas Counties		Lake, Lorain, and Lucas Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	062	0	2021	01	AARP Medicare Advantage Plan 5 (HMO)	Central Ohio area		Central Ohio area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	064	0	2021	02	UnitedHealthcare Assisted Living Plan (HMO-POS I-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	067	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Lexington Metro area & Southeastern Kentucky		Lexington Metro area & Southeastern Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	072	0	2021	02	AARP Medicare Advantage Value (HMO-POS)	Central Wisconsin		Central Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	073	0	2021	02	AARP Medicare Advantage (HMO-POS)	Central Wisconsin		Central Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	079	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Asheville Area		Asheville Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $170.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $170.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	080	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Asheville Area		Asheville Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	081	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Memphis Metro Area		Memphis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	082	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Memphis Metro Area		Memphis Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130			memberservices@mypreferredcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	083	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Nashville Metro Area		Nashville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	084	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Nashville Metro Area		Nashville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	087	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Southeastern Virginia		Southeastern Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	088	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Southeastern Virginia		Southeastern Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	089	0	2021	02	AARP Medicare Advantage (HMO-POS)	Northern VA and Washington DC Area		Northern VA and Washington DC Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	091	0	2021	01	AARP Medicare Advantage Plan 3 (HMO)	Lexington Metro area & Southeastern Kentucky		Lexington Metro area & Southeastern Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	097	0	2021	01	AARP Medicare Advantage Value (HMO)	Southern Wisconsin		Southern Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $405.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $405.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	099	0	2021	01	AARP Medicare Advantage Plan 1 (HMO)	Louisville Metro Area		Louisville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	100	0	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Louisville Metro Area		Louisville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	102	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Durham and Wake Counties		Durham and Wake Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	103	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Select counties in North Carolina		Select counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $170.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $170.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	104	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Select counties in North Carolina		Select counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	105	0	2021	02	AARP Medicare Advantage Walgreens (HMO-POS)	Buncombe, McDowell, and Transylvania counties		Buncombe, McDowell, and Transylvania counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	107	1	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Select Counties in Iowa		Iowa Metro	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	107	2	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Select Counties in Iowa		Iowa Rural	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	108	1	2021	02	AARP Medicare Advantage (HMO-POS)	Northwestern Illinois		Northwestern Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	108	2	2021	02	AARP Medicare Advantage (HMO-POS)	Northwestern Illinois		Henry, Mercer and Rock Island Counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	108	3	2021	02	AARP Medicare Advantage (HMO-POS)	Northwestern Illinois		Select Counties in Iowa	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	109	1	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select Counties in Ohio and Kentucky		Central Ohio Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	109	2	2021	01	AARP Medicare Advantage Plan 2 (HMO)	Select Counties in Ohio and Kentucky		Cincinnati/Dayton Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	110	0	2021	02	AARP Medicare Advantage Walgreens (HMO-POS)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	111	1	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Roanoke/Richmond Metro Area		Roanoke	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	111	2	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Roanoke/Richmond Metro Area		Richmond	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	112	1	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Richmond and Roanoke Metro Area		Roanoke	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	112	2	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Richmond and Roanoke Metro Area		Richmond	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	113	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Select Counties in Tennessee and Virginia		Select Counties in Tennessee and Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H5253	801	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Milwaukee and Green Bay Area Counties		Milwaukee and Green Bay Area Counties	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	802	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Milwaukee and Green Bay Area Counties		Milwaukee and Green Bay Area Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	805	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select Counties in WI		Select Counties in WI	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	810	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	811	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	812	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Arizona		Arizona	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	813	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in North Carolina		Select counties in North Carolina	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	814	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in North Carolina		Select counties in North Carolina	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	815	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in North Carolina		Select counties in North Carolina	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	816	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in North Carolina		Select counties in North Carolina	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	817	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in North Carolina		Select counties in North Carolina	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	818	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in IA, IL, TN, & VA		Select counties in IA, IL, TN, & VA	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	819	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in IA, IL, TN, & VA		Select counties in IA, IL, TN, & VA	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	820	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in IA, IL, TN, & VA		Select counties in IA, IL, TN, & VA	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	821	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Kentucky and Ohio		Select counties in Kentucky and Ohio	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	822	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Kentucky and Ohio		Select counties in Kentucky and Ohio	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	823	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select counties in Kentucky and Ohio		Select counties in Kentucky and Ohio	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	824	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select AZ Counties		Select AZ Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5253	825	0	2021	01	UnitedHealthcare Group Medicare Advantage (HMO)	Select AZ Counties		Select AZ Counties	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5256	001	0	2021	18	Medical Associates SmartPlan (Cost)	Grant, Crawford, Iowa, Lafayette Counties		Grant, Crawford, Iowa, Lafayette Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H5256	002	0	2021	18	Medical Associates Community Plan (Cost)	Grant, Crawford, Iowa, Lafayette Counties		Grant, Crawford, Iowa, Lafayette Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H5256	004	0	2021	18	Medical Associates Freedom Plan (Cost)	Grant, Crawford, Iowa, Lafayette Counties		Grant, Crawford, Iowa, Lafayette Counties	1	0	0	1605 Associates Drive		Dubuque	IA	52002		rsnyder@mahealthcare.com	memberservices@mahealthcare.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mahealthplans.com	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.mahealthplans.com		
H5262	001	0	2021	01	Gundersen Quartz Med Advantage Elite D (w/Rx) (HMO)	La Crosse and SW Wisconsin and NE Iowa		La Crosse and SW Wisconsin and NE Iowa	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	003	0	2021	01	Gundersen Quartz Med Advantage Value D (w/Rx) (HMO)	La Crosse and SW Wisconsin and NE Iowa		La Crosse and SW Wisconsin and NE Iowa	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	004	0	2021	01	Gundersen Quartz Med Advantage Value (HMO)	La Crosse and SW Wisconsin and NE Iowa		La Crosse and SW Wisconsin and NE Iowa	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	005	0	2021	01	Gundersen Quartz Med Advantage Elite (HMO)	La Crosse and SW Wisconsin and NE Iowa		La Crosse and SW Wisconsin and NE Iowa	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	007	0	2021	01	UW Health Quartz Med Advantage Elite D (w/Rx) (HMO)	Southcentral Wisconsin		Southcentral Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	008	0	2021	01	UW Health Quartz Med Advantage Value D (w/Rx) (HMO)	Southcentral Wisconsin		Southcentral Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	009	0	2021	01	UW Health Quartz Med Advantage Value (HMO)	Southcentral Wisconsin		Southcentral Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	010	0	2021	01	UW Health Quartz Med Advantage Elite (HMO)	Southcentral Wisconsin		Southcentral Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	011	0	2021	01	Aurora Health Quartz Med Advantage Value D (w/Rx) (HMO)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	012	0	2021	01	Aurora Health Quartz Med Advantage Core D (w/Rx) (HMO)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	013	0	2021	01	Aurora Health Quartz Med Advantage Value (HMO)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	018	0	2021	01	SwedishAmerican Quartz Med Advantage Value D(w/Rx) (HMO)	Northcentral Illinois		Northcentral Illinois	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	019	0	2021	01	SwedishAmerican Quartz Med Advantage Core D (w/Rx) (HMO)	Northcentral Illinois		Northcentral Illinois	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	020	0	2021	01	SwedishAmerican Quartz Med Advantage Value (HMO)	Northcentral Illinois		Northcentral Illinois	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	021	0	2021	01	Gundersen Quartz Med Advantage Core D (w/Rx) (HMO)	La Crosse and SW Wisconsin and NE Iowa		La Crosse and SW Wisconsin and NE Iowa	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	023	0	2021	01	UW Health Quartz Med Advantage Core D (w/Rx) (HMO)	Southcentral Wisconsin		Southcentral Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	024	0	2021	01	Aurora Health Quartz Med Advantage Elite D (w/Rx) (HMO)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	025	0	2021	01	Aurora Health Quartz Med Advantage Elite (HMO)	Eastern Wisconsin		Eastern Wisconsin	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	026	0	2021	01	SwedishAmerican Quartz Med Advantage Elite D(w/Rx) (HMO)	Northcentral Illinois		Northcentral Illinois	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	027	0	2021	01	SwedishAmerican Quartz Med Advantage Elite (HMO)	Northcentral Illinois		Northcentral Illinois	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5262	801	0	2021	01	Employer Group Quartz Medicare Advantage D (w/Rx) (HMO)	Southern WI, Northcentral IL, and Northeast IA		Southern WI, Northcentral IL, and Northeast IA	1	3	1	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H5262	802	0	2021	01	Employer Group Quartz Medicare Advantage (HMO)	Southern WI, Northcentral IL, and Northeast IA		Southern WI, Northcentral IL, and Northeast IA	1	3	1	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H5264	002	0	2021	18	DeanCare Gold Enhanced (Cost)	South Central Wisconsin	DeanCare Gold Enhanced (Cost)	South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	deancare.com/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.deancare.com/find-a-doctor		
H5264	003	0	2021	18	DeanCare Gold Basic (Cost)	South Central Wisconsin	DeanCare Gold Basic (Cost)	South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	deancare.com/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.deancare.com/find-a-doctor		
H5264	005	0	2021	18	DeanCare Gold Shared Value (Cost)	South Central Wisconsin	DeanCare Gold Shared Value (Cost)	South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	deancare.com/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.deancare.com/drugformulary		
H5273	001	0	2021	01	CarePartners of CT CareAdvantage Preferred (HMO)	Most of Connecticut		Most of Connecticut	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.carepartnersct.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerC	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerC	www.carepartnersct.com/drug-search
H5273	002	0	2021	01	CarePartners of CT CareAdvantage Prime (HMO)	Most of Connecticut		Most of Connecticut	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.carepartnersct.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerC	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerC	www.carepartnersct.com/drug-search
H5273	003	0	2021	01	CarePartners of CT CareAdvantage Premier (HMO)	Most of Connecticut		Most of Connecticut	1	0	0	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	705 Mt. Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Michael_Fopiano@tufts-health.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.carepartnersct.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerC	https://tuftsweb.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerC	www.carepartnersct.com/drug-search
H5280	001	0	2021	48	Molina Dual Options – MyCareOhio (Medicare-Medicaid Plan)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	3000 Corporate Exchange Drive		Columbus	OH	43231				200 Oceangate	Suite 100	Long Beach	CA	90802				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H5294	010	0	2021	01	Allwell Medicare Nurture (HMO D-SNP)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	011	0	2021	01	Allwell Medicare (HMO)	Rio Grande Valley and Corpus Christi Area		Rio Grande Valley and Corpus Christi Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	012	0	2021	01	Allwell Medicare Boost (HMO)	Rio Grande Valley and Corpus Christi Area		Rio Grande Valley and Corpus Christi Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	013	0	2021	01	Allwell Medicare Complement (HMO)	Rio Grande Valley and Corpus Christi Area		Rio Grande Valley and Corpus Christi Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	014	0	2021	01	Allwell Medicare Simple (HMO)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	015	0	2021	01	Allwell Dual Medicare Harmony (HMO D-SNP)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	016	0	2021	01	Allwell Medicare Complement (HMO)	Select Counties Statewide		Select Counties Statewide	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	017	0	2021	01	Allwell Medicare (HMO)	San Antonio and surrounding counties		San Antonio and surrounding counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5294	018	0	2021	01	Allwell Medicare (HMO)	Lubbock County		Lubbock County	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.superiorhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/findadoctor	allwell.superiorhealthplan.com/formulary
H5296	001	0	2021	01	NC Premier (HMO)	Wake, Chatham, Johnston		Wake, Chatham, Johnston	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H5296	002	0	2021	01	NCPlus (HMO)	Wake, Chatham, Johnston		Wake, Chatham, Johnston	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H5296	003	0	2021	02	Platinum (HMO-POS)	Wake, Chatham, Johnston		Wake, Chatham, Johnston	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H5302	011	0	2021	01	Aetna Medicare Advantra Platinum Plan (HMO)	Select Counties in Atlanta Area		Select Counties in Atlanta Area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	GoldenMedicare@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5302	012	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Atlanta Metro		Atlanta Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5302	013	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Cobb County		Cobb County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5302	014	0	2021	01	Aetna Medicare Dual Preferred Plan (HMO D-SNP)	Savannah		Savannah	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5302	809	0	2021	01	Aetna Medicare Plan (HMO)	Georgia		Georgia	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5302	810	0	2021	01	Aetna Medicare w/Rx Plan (HMO)	Georgia		Georgia	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5322	001	0	2021	02	UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)	Select Counties in OH, SC and VA		Select Counties in OH, SC and VA	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5322	003	0	2021	01	UnitedHealthcare Nursing Home Plan (HMO I-SNP)	Select Counties in FL and NJ		Select Counties in FL and NJ	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	1	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5322	004	0	2021	02	UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)	Atlanta and Augusta Metro areas		Atlanta and Augusta Metro areas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCMedicareSolutions.com	1	1	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5322	025	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Texas		Select Counties in Texas	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5322	026	0	2021	01	UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)	Cameron, Hidalgo, and Willacy Counties		Cameron, Hidalgo, and Willacy Counties	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5322	028	0	2021	02	UnitedHealthcare Dual Complete (HMO-POS D-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCCommunityPlan.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5322	029	0	2021	02	UnitedHealthcare Dual Complete LP (HMO-POS D-SNP)	Select Counties in Kansas		Select Counties in Kansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCCommunityPlan.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5322	030	0	2021	02	UnitedHealthcare Dual Complete (HMO-POS D-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	1	www.UHCCommunityPlan.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5322	031	0	2021	01	UnitedHealthcare Dual Complete LP (HMO D-SNP)	Select Counites in OK		Select Counites in OK	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H5325	001	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Eastern Kansas		Eastern Kansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5325	002	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Central Kansas		Central Kansas	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5325	003	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Kansas City Metro		Kansas City Metro	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5325	004	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Southwest Missouri		Southwest Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5325	005	0	2021	01	Aetna Medicare Assure Gold Prime (HMO D-SNP)	Missouri		Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@Aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5325	006	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Missouri		Missouri	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5337	001	0	2021	01	Aetna Medicare Assure (HMO D-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5355	001	0	2021	48	IEHP DualChoice (Medicare-Medicaid Plan)	Riverside and San Bernardino Counties	IEHP DualChoice (Medicare-Medicaid Plan)	Riverside and San Bernardino Counties	1	0	0	P.O. Box 1800		Rancho Cucamonga	CA	91729				P.O. Box 1800		Rancho Cucamonga	CA	91729				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.iehp.org	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.iehp.org	www.iehp.org	www.iehp.org
H5373	001	0	2021	01	ProMedica Medicare Plan Essential Medical and Drug (HMO)	Essential Medical and Drug NE Indiana		Essential Medical and Drug NE Indiana	1	0	0	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.promedicahealthplan.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.promedicahealthplan.com/medicare	www.promedicahealthplan.com/medicare	www.promedicahealthplan.com/medicare
H5374	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	NC service areas		NC service areas	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H5377	001	0	2021	01	Humana Gold Plus H5377-001 (HMO)	Roanoke Metro Area		Roanoke Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5386	003	0	2021	01	Sharp Direct Advantage Gold Card (HMO)	Sharp Direct Advantage Gold San Diego County		Sharp Direct Advantage Gold San Diego County	1	0	0	8520 Tech Way	Suite 201	San Diego	CA	92123				8520 Tech Way	Suite 201	San Diego	CA	92123				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	sharpmedicareadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	sharpmedicareadvantage.com	sharpmedicareadvantage.com	sharpmedicareadvantage.com
H5386	004	0	2021	01	Sharp Direct Advantage Platinum Card (HMO)	Sharp Direct Advantage Platinum San Diego County		Sharp Direct Advantage Platinum San Diego County	1	0	0	8520 Tech Way	Suite 201	San Diego	CA	92123				8520 Tech Way	Suite 201	San Diego	CA	92123				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	sharpmedicareadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	sharpmedicareadvantage.com	sharpmedicareadvantage.com	sharpmedicareadvantage.com
H5386	801	0	2021	01	Sharp Direct Advantage Calendar Year (HMO)	Sharp Direct Advantage San Diego County		Sharp Direct Advantage San Diego County	1	3	1	8520 Tech Way	Suite 201	San Diego	CA	92123				8520 Tech Way	Suite 201	San Diego	CA	92123				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	sharpmedicareadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	sharpmedicareadvantage.com	sharpmedicareadvantage.com	sharpmedicareadvantage.com
H5386	802	0	2021	01	Sharp Direct Advantage Non-Calendar Year (HMO)	Sharp Direct Advantage San Diego County		Sharp Direct Advantage San Diego County	1	3	1	8520 Tech Way	Suite 201	San Diego	CA	92123				8520 Tech Way	Suite 201	San Diego	CA	92123				5000000000208002000308002000408002000508002000608002000000000000	5000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	sharpmedicareadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	sharpmedicareadvantage.com	sharpmedicareadvantage.com	sharpmedicareadvantage.com
H5386	803	0	2021	01	Sharp Direct Advantage MA Only (HMO)	Sharp Direct Advantage San Diego County		Sharp Direct Advantage San Diego County	1	3	1	8520 Tech Way	Suite 201	San Diego	CA	92123												5000000000208002000308002000408002000508002000608002000000000000	5000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	sharpmedicareadvantage.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	sharpmedicareadvantage.com	sharpmedicareadvantage.com	sharpmedicareadvantage.com
H5398	001	0	2021	01	Ascension Complete Via Christi Reward (HMO)	Butler, Harvey and Sedgwick Counties		Butler, Harvey and Sedgwick Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/ks-findadoctor	ascensioncomplete.com/ks-findadoctor	ascensioncomplete.com/ks-formulary
H5398	002	0	2021	01	Ascension Complete Via Christi Secure (HMO)	Butler, Harvey and Sedgwick Counties		Butler, Harvey and Sedgwick Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/ks-findadoctor	ascensioncomplete.com/ks-findadoctor	ascensioncomplete.com/ks-formulary
H5403	001	0	2021	20	On Lok PACE (Dual Eligibles) (PACE)	San Francisco, Alameda and Santa Clara counties		San Francisco, Alameda and Santa Clara counties	1	3	0									1333 Bush Street		San Francisco	CA	94109		info@onlok.org	memberservices@onlok.org	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.onlok.org/PACE	0	0	1			0					3	0	0		www.onlok.org/PACE	N/A
H5403	002	0	2021	20	On Lok PACE (Medicare Only) (PACE)	San Francisco, Alameda and Santa Clara counties		San Francisco, Alameda and Santa Clara counties	1	3	0									1333 Bush Street		San Francisco	CA	94109		info@onlok.org	memberservices@onlok.org	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.onlok.org/PACE	0	0	1			0					3	0	0		www.onlok.org/PACE	N/A
H5405	001	0	2021	20	Center for Elders' Independence - Part D (PACE)	Alameda and Contra Costa Counties		Alameda and Contra Costa Counties	1	3	0									510-17th St.		Oakland	CA	94612		cyi@cei.elders.org	cyi@cei.elders.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cei.elders.org	0	0	1			0					3	0	0		www.cei.elders.org	www.cei.elders.org
H5405	002	0	2021	20	Center for Elders' Independence (PACE)	Alameda and Contra Costa Counties		Alameda and Contra Costa Counties	1	3	0									510-17th St.		Oakland	CA	94612		cyi@cei.elders.org	cyi@cei.elders.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cei.elders.org	0	0	1			0					3	0	0		www.cei.elders.org	www.cei.elders.org
H5406	001	0	2021	20	Sutter SeniorCare (PACE)	Sacramento Counties	Sutter SeniorCare (PACE)	Sacramento Counties	1	3	0									444 North 3rd Street		Sacramento	CA	95811		ansleyp@sutterhealth.org	ansleyp@sutterhealth.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sutterseniorcare.org	0	0	1			0					3	0	0	N/A	N/A	N/A
H5406	002	0	2021	20	Sutter SeniorCare (PACE)	Yolo Counties	Sutter SeniorCare (PACE)	Yolo Counties	1	3	0									444 North 3rd Street		Sacramento	CA	95811		ansleyp@sutterhealth.org	ansleyp@sutterhealth.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sutterseniorcare.org	0	0	1			0					3	0	0	N/A	N/A	N/A
H5410	001	0	2021	01	Leon Medicare (HMO)	Miami-Dade county	Leon Medicare (HMO)	Miami-Dade county	1	0	0	PO Box 669440		Miami	FL	33166				PO Box 669440		Miami	FL	33166				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	0	4	Approved by Medicare	Aprobado por Medicare	0	www.lmchealthplans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0		www.lmchealthplans.com	www.lmchealthplans.com
H5410	004	0	2021	01	Cigna Fundamental Medicare (HMO)	Northern Florida	Cigna Fundamental Medicare (HMO)	Northern Florida	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	013	0	2021	01	Cigna TotalCare (HMO D-SNP)	Northern Florida	Cigna TotalCare (HMO D-SNP)	Northern Florida	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	018	0	2021	01	Cigna Preferred Medicare (HMO)	Northern Florida	Cigna Preferred Medicare (HMO)	Northern Florida	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	024	0	2021	01	Cigna Preferred Medicare (HMO)	Orlando Area	Cigna Preferred Medicare (HMO)	Orlando Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	025	0	2021	01	Cigna TotalCare (HMO D-SNP)	Orlando Area	Cigna TotalCare (HMO D-SNP)	Orlando Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	026	0	2021	01	Cigna Preferred Savings Medicare (HMO)	Orlando Area	Cigna Preferred Savings Medicare (HMO)	Orlando Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	027	0	2021	01	Cigna Preferred Medicare (HMO)	Daytona Area	Cigna Preferred Medicare (HMO)	Daytona Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	028	0	2021	01	Cigna Preferred Savings Medicare (HMO)	Daytona Area	Cigna Preferred Savings Medicare (HMO)	Daytona Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	029	0	2021	01	Cigna Preferred Medicare (HMO)	Tampa Area	Cigna Preferred Medicare (HMO)	Tampa Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	030	0	2021	01	Cigna Preferred Savings Medicare (HMO)	Tampa Area	Cigna Preferred Savings Medicare (HMO)	Tampa Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	031	0	2021	01	Cigna TotalCare (HMO D-SNP)	Daytona Area	Cigna TotalCare (HMO D-SNP)	Daytona Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	032	0	2021	01	Cigna TotalCare (HMO D-SNP)	Tampa Area	Cigna TotalCare (HMO D-SNP)	Tampa Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	033	0	2021	01	Cigna Primary Medicare (HMO)	Orlando Area	Cigna Primary Medicare (HMO)	Orlando Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	034	0	2021	01	Cigna Primary Medicare (HMO)	Daytona Area	Cigna Primary Medicare (HMO)	Daytona Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	035	0	2021	01	Cigna Primary Medicare (HMO)	Tampa Area	Cigna Primary Medicare (HMO)	Tampa Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	036	0	2021	01	Cigna Preferred Medicare (HMO)	Sumter County	Cigna Preferred Medicare (HMO)	Sumter County	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
H5410	807	0	2021	01	Leon Medicare Group Plan (HMO)	Statewide FL	Leon Medicare Group Plan (HMO)	Statewide FL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TN	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TN	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignahealthspring.com
H5410	808	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide FL	Cigna Preferred Medicare (HMO)	Statewide FL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0		www.cigna.com/medicare	www.cignahealthspring.com
H5420	001	0	2021	01	Medica HealthCare Plans MedicareMax (HMO)	Miami-Dade County		Miami-Dade County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicaplans.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.Medicaplans.com	www.Medicaplans.com	www.Medicaplans.com
H5420	003	0	2021	01	Medica HealthCare Plans MedicareMax (HMO)	Broward County		Broward County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicaplans.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.Medicaplans.com	www.Medicaplans.com	www.Medicaplans.com
H5420	006	0	2021	01	Medica HealthCare Plans MedicareMax Plus (HMO D-SNP)	Miami-Dade and Broward County		Miami-Dade and Broward County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Medicaplans.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Medicaplans.com	www.Medicaplans.com	www.Medicaplans.com
H5422	007	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.bcbsga.com/medicare	https://shop.bcbsga.com/medicare
H5422	008	0	2021	01	Anthem MediBlue Essential (HMO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.bcbsga.com/medicare	https://shop.bcbsga.com/medicare
H5422	011	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.bcbsga.com/medicare	https://shop.bcbsga.com/medicare
H5422	013	0	2021	01	Anthem MediBlue Extra (HMO)	Select counties in Georgia		Select counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H5422	014	0	2021	01	Anthem MediBlue Core (HMO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com										2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	https://shop.bcbsga.com/medicare	https://shop.bcbsga.com/medicare
H5422	803	0	2021	01	BlueValue (HMO)	Georgia Select Counties		Georgia Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsga.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bcbsga.com/medicare	www.bcbsga.com/medicare	www.bcbsga.com/medicare
H5422	804	0	2021	01	BlueValue (HMO)	Georgia - Select Counties		Georgia - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsga.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bcbsga.com/medicare	www.bcbsga.com/medicare	www.bcbsga.com/medicare
H5422	806	0	2021	01	BlueValue (HMO)	Georgia - Select counties		Georgia - Select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsga.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bcbsga.com/medicare	www.bcbsga.com/medicare	www.bcbsga.com/medicare
H5422	807	0	2021	01	BlueValue (HMO)	Select Georgia Counties		Select Georgia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ga/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare
H5422	808	0	2021	01	BlueValue (HMO)	Select Georgia Counties		Select Georgia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ga/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare
H5422	809	0	2021	01	BlueValue (HMO)	Select Georgia Counties		Select Georgia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ga/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare
H5422	810	0	2021	01	BlueValue (HMO)	Select Georgia Counties		Select Georgia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ga/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare
H5422	811	0	2021	01	Blue Value (HMO)	Select Georgia Counties		Select Georgia Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ga/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare	www.anthem.com/ga/medicare
H5425	001	0	2021	01	SCAN Classic (HMO)	Ventura County	SCAN Classic (HMO)	Ventura County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	004	0	2021	01	Scripps Signature offered by SCAN Health Plan (HMO)	San Diego County	Scripps Signature offered by SCAN Health Plan (HMO)	San Diego County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	005	0	2021	01	Scripps Classic offered by SCAN Health Plan (HMO)	San Diego County	Scripps Classic offered by SCAN Health Plan (HMO)	San Diego County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	006	0	2021	01	SCAN Classic (HMO)	Los Angeles County	SCAN Classic (HMO)	Los Angeles County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	007	0	2021	01	SCAN Classic (HMO)	Orange County	SCAN Classic (HMO)	Orange County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	008	0	2021	01	SCAN Classic (HMO)	Riverside County	SCAN Classic (HMO)	Riverside County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	009	0	2021	01	SCAN Classic (HMO)	San Bernardino County	SCAN Classic (HMO)	San Bernardino County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	010	0	2021	01	SCAN Connections (HMO D-SNP)	Los Angeles, Riverside and San Bernardino Counties	SCAN Connections (HMO D-SNP)	Los Angeles, Riverside and San Bernardino Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	019	0	2021	01	SCAN Classic (HMO)	San Francisco County	SCAN Classic (HMO)	San Francisco County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	020	0	2021	01	SCAN Classic (HMO)	Santa Clara County	SCAN Classic (HMO)	Santa Clara County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	028	0	2021	01	SCAN Heart First (HMO C-SNP)	Orange County	SCAN Heart First (HMO C-SNP)	Orange County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	030	0	2021	01	SCAN Connections at Home (HMO D-SNP)	Los Angeles, Riverside and San Bernardino Counties	SCAN Connections at Home (HMO D-SNP)	Los Angeles, Riverside and San Bernardino Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	033	0	2021	01	SCAN Heart First (HMO C-SNP)	Riverside and San Bernardino Counties	SCAN Heart First (HMO C-SNP)	Riverside and San Bernardino Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	034	0	2021	01	SCAN Balance (HMO C-SNP)	Los Angeles and Orange Counties	SCAN Balance (HMO C-SNP)	Los Angeles and Orange Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	040	0	2021	01	Scripps Plus offered by SCAN Health Plan (HMO)	San Diego County	Scripps Plus offered by SCAN Health Plan (HMO)	San Diego County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	045	0	2021	01	SCAN Plus (HMO)	Selected Southern and Northern CA Counties	SCAN Plus (HMO)	Selected Southern and Northern CA Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	052	0	2021	01	SCAN Classic (HMO)	Napa and Sonoma Counties	SCAN Classic (HMO)	Napa and Sonoma Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	053	0	2021	01	SCAN Heart First (HMO C-SNP)	Napa and Sonoma Counties	SCAN Heart First (HMO C-SNP)	Napa and Sonoma Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	054	0	2021	01	SCAN Balance (HMO C-SNP)	Napa and Sonoma Counties	SCAN Balance (HMO C-SNP)	Napa and Sonoma Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	055	0	2021	01	Scripps Heart First offered by SCAN Health Plan (HMO C-SNP)	San Diego County	Scripps Heart First offered by SCAN Health Plan (HMO C-SNP)	San Diego County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	064	0	2021	01	SCAN Classic II (HMO)	Los Angeles County	SCAN Classic II (HMO)	Los Angeles County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	065	0	2021	01	SCAN Prime (HMO)	Los Angeles County	SCAN Prime (HMO)	Los Angeles County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	066	0	2021	01	SCAN Prime (HMO)	Orange County	SCAN Prime (HMO)	Orange County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	067	0	2021	01	SCAN Prime (HMO)	Riverside County	SCAN Prime (HMO)	Riverside County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	068	0	2021	01	SCAN Prime (HMO)	San Bernardino County	SCAN Prime (HMO)	San Bernardino County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	069	0	2021	01	SCAN Classic (HMO)	Stanislaus County	SCAN Classic (HMO)	Stanislaus County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	070	0	2021	01	SCAN Balance (HMO C-SNP)	Stanislaus County	SCAN Balance (HMO C-SNP)	Stanislaus County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	071	0	2021	01	SCAN Plus (HMO)	Stanislaus County	SCAN Plus (HMO)	Stanislaus County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	072	0	2021	01	SCAN Plus (HMO)	Santa Clara County	SCAN Plus (HMO)	Santa Clara County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	073	0	2021	01	SCAN Options (HMO)	Santa Clara County	SCAN Options (HMO)	Santa Clara County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	074	0	2021	01	SCAN Compass (HMO)	Napa and Sonoma Counties	SCAN Compass (HMO)	Napa and Sonoma Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H5425	803	0	2021	01	SCAN Retiree Group (HMO)	Southern and Northern California Counties	SCAN Retiree Group (HMO)	Southern and Northern California Counties	1	3	1	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	https://www.scanhealthplan.com/	https://www.scanhealthplan.com/
H5425	804	0	2021	01	SCAN Retiree Group (HMO)	Southern and Northern California Counties	SCAN Retiree Group (HMO)	Southern and Northern California Counties	1	3	1	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	https://www.scanhealthplan.com/	https://www.scanhealthplan.com/
H5427	052	0	2021	01	Freedom Savings Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	059	0	2021	01	Freedom Medicare Plan Rx (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	060	0	2021	01	Freedom Medicare Plan Rx (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	070	0	2021	01	Freedom VIP Care (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	072	0	2021	01	Freedom VIP Savings (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	077	0	2021	01	Freedom VIP Savings COPD (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	078	0	2021	01	Freedom Medi-Medi Partial (HMO D-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	082	0	2021	01	Freedom VIP Savings (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	083	0	2021	01	Freedom VIP Savings COPD (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	087	0	2021	01	Freedom Medi-Medi Full (HMO D-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	088	0	2021	01	Freedom Platinum Plan Rx (HMO)	select counties in Florida		select counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	089	0	2021	01	Freedom Platinum Plan Rx (HMO)	Select Counties in FL		Select Counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	091	0	2021	01	Freedom Platinum Plan Rx (HMO)	Select Counties in FL		Select Counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	092	0	2021	01	Freedom Platinum Plan Rx (HMO)	Select Counties in FL		Select Counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	093	0	2021	01	Freedom Platinum Plan Rx (HMO)	Select Counties in FL		Select Counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	094	0	2021	01	Freedom Platinum Plan Rx (HMO)	Select Counties in FL		Select Counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	096	0	2021	01	Freedom Platinum Rewards Plan Rx (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	098	0	2021	01	Freedom Platinum Plan Rx (HMO)	select counties in FL		select counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	099	0	2021	01	Freedom VIP Rewards (HMO C-SNP)	select counties in FL		select counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.FreedomHealth.com	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	102	0	2021	01	Freedom Platinum Rewards Plan Rx (HMO)	select counties in FL		select counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5427	103	0	2021	01	Freedom Platinum Rewards Plan Rx (HMO)	select counties in FL		select counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@freedomh.com	member_services@freedomh.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.FreedomHealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	http://www.FreedomHealth.com	www.freedomhealth.com	www.freedomhealth.com
H5430	001	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5431	001	0	2021	01	HealthSun HealthAdvantage Plan (HMO)	Miami-Dade		Miami-Dade	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@Healthsun.com	HSComplianceTeam@Healthsun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@Healthsun.com	HSComplianceTeam@Healthsun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5431	006	0	2021	01	HealthSun MediMax (HMO)	Broward and Miami-Dade		Broward and Miami-Dade	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5431	012	0	2021	01	HealthSun HealthAdvantage Plan (HMO)	Broward County		Broward County	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5431	013	0	2021	01	HealthSun HealthAdvantage Plan (HMO)	Palm Beach		Palm Beach	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	cms_compliance@Healthsun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	cms_compliance@Healthsun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5431	014	0	2021	01	HealthSun MediMax (HMO)	Palm Beach		Palm Beach	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5431	015	0	2021	01	HealthSun MediSun Plus (HMO D-SNP)	Miami-Dade, Broward		Miami-Dade, Broward	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5431	016	0	2021	01	HealthSun MediSun Plus (HMO D-SNP)	Palm Beach		Palm Beach	1	0	0	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	9250 W. Flagler Street	Suite 600	Miami	FL	33174		HSComplianceTeam@HealthSun.com	HSComplianceTeam@HealthSun.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HealthSun.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.HealthSun.com	www.HealthSun.com	www.HealthSun.com
H5433	001	0	2021	01	OneCare (HMO D-SNP)	Orange County, California	OneCare (HMO D-SNP)	Orange County, California	1	0	0	505 City Parkway West		Orange	CA	92868				505 City Parkway West		Orange	CA	92868				5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	https://www.caloptima.org/en/ForMembers/OneCare	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.caloptima.org/en/ForMembers/OneCare/FindAProvider.aspx	https://www.caloptima.org/en/ForMembers/OneCare/FindAProvider/PharmacySearch.aspx	https://www.caloptima.org/en/ForMembers/OneCare/Pharmacy.aspx
H5434	002	0	2021	04	BlueMedicare Select (PPO)	Select counties in S.FL/ W.FL/C.FL,N.C. FL/N.W FL	BlueMedicare Select (PPO)	Select counties in S.FL/ W.FL/C.FL,N.C. FL/N.W FL	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $305.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $305.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	023	0	2021	04	BlueMedicare Value (PPO)	Pinellas County		Pinellas County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/Medicare	FloridaBlue.com/Medicare	MyPrime.com
H5434	024	0	2021	04	BlueMedicare Value (PPO)	Manatee & Sarasota counties		Manatee & Sarasota counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	025	0	2021	04	BlueMedicare Value (PPO)	Escambia, Okaloosa & Santa Rosa counties		Escambia, Okaloosa & Santa Rosa counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	026	0	2021	04	BlueMedicare Value (PPO)	BRO, IND, MART, PAL, & SLU counties		BRO, IND, MART, PAL, & SLU counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	030	0	2021	04	BlueMedicare Value (PPO)	Charlotte, Collier & Lee counties		Charlotte, Collier & Lee counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	031	0	2021	04	BlueMedicare Value (PPO)	Clay & Duval counties		Clay & Duval counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	032	0	2021	04	BlueMedicare Value (PPO)	Miami-Dade County		Miami-Dade County	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	033	0	2021	04	BlueMedicare Value (PPO)	Brevard, Orange, Osceola & Seminole  counties		Brevard, Orange, Osceola & Seminole  counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	034	0	2021	04	BlueMedicare Value (PPO)	Hillsborough & Polk counties		Hillsborough & Polk counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	035	0	2021	04	BlueMedicare Value (PPO)	Hernando & Pasco counties		Hernando & Pasco counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	036	0	2021	04	BlueMedicare Value (PPO)	Lake, Marion, & Sumter counties		Lake, Marion, & Sumter counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	038	0	2021	04	BlueMedicare Patriot (PPO)	Lake, Marion, & Sumter counties		Lake, Marion, & Sumter counties	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	801	0	2021	04	BlueMedicare Group PPO (PPO)	State of Florida with National Coverage		State of Florida with National Coverage	1	3	1	4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5434	802	0	2021	04	BlueMedicare Group PPO (PPO)	State of Florida with National Coverage		State of Florida with National Coverage	1	3	1	4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 200 / 4th Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
H5435	001	0	2021	09	UnitedHealthcare MedicareDirect Patriot (PFFS)	Select counties nationwide		Select counties nationwide	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2			0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5435	024	0	2021	09	UnitedHealthcare MedicareDirect Rx (PFFS)	Select counties nationwide		Select counties nationwide	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H5439	010	0	2021	04	Health Net Aqua (PPO)	Northern Counties	Health Net Aqua (PPO)	Northern Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H5439	011	0	2021	04	Health Net Violet 1 (PPO)	Northern Counties	Health Net Violet 1 (PPO)	Northern Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H5439	015	0	2021	04	Health Net Violet 3 (PPO)	BE, CK, DO, JC, JO, LA, LN, MN, ML, PK, WA, YM, CR	Health Net Violet 3 (PPO)	BE, CK, DO, JC, JO, LA, LN, MN, ML, PK, WA, YM, CR	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H5439	017	0	2021	04	Health Net Violet 4 (PPO)	Lane County		Lane County	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H5439	018	0	2021	04	Health Net Violet 2 (PPO)	10 Northern Counties	Health Net Violet 2 (PPO)	10 Northern Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H5439	019	0	2021	04	Health Net Violet 2 (PPO)	Douglas, Jackson, Josephine	Health Net Violet 2 (PPO)	Douglas, Jackson, Josephine	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H5439	801	0	2021	04	Health Net Medicare Advantage Employer (PPO)	48 States - All Counties	Health Net Medicare Advantage Employer (PPO)	48 States - All Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H5439	802	0	2021	04	Health Net Medicare Advantage Employer (PPO)	48 States - All Counties	Health Net Medicare Advantage Employer (PPO)	48 States - All Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H5439	803	0	2021	04	Health Net Medicare Advantage Employer (PPO)	48 States - All Counties	Health Net Medicare Advantage Employer (PPO)	48 States - All Counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H5439	804	0	2021	04	Allwell Medicare (PPO)	48 States- All counties	Allwell Medicare (PPO)	48 States- All counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H5439	805	0	2021	04	Allwell Medicare (PPO)	48 States- All counties	Allwell Medicare (PPO)	48 States- All counties	1	3	1	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H5447	001	0	2021	01	CFHP Medicare Advantage with Part D Standard Plan (HMO)	South Texas		South Texas	1	0	0	12238 Silicon Drive, Suite 100		San Antonio	TX	78249				12238 Silicon Drive, Suite 100		San Antonio	TX	78249				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://communityfirstmedicare.com/	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://communityfirstmedicare.com/	https://www.navitus.com/	https://medicarerx.navitus.com/
H5447	002	0	2021	01	CFHP Medicare Advantage D-SNP Standard Plan (HMO D-SNP)	South Texas		South Texas	1	0	0	12238 Silicon Drive, Suite 100		San Antonio	TX	78249				12238 Silicon Drive, Suite 100		San Antonio	TX	78249				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://www.CFHP.com/	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.CFHP.com/	https://www.navitus.com/	https://medicarerx.navitus.com/
H5454	001	0	2021	01	Clear Spring Health Essential (HMO)	Rockford, Metro St Louis		Rockford, Metro St Louis	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H5454	002	0	2021	01	Clear Spring Health Essential (HMO)	Metro Chicago		Metro Chicago	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H5471	064	0	2021	01	Simply Complete (HMO D-SNP)	Miami-Dade		Miami-Dade	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefits	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5471	065	0	2021	01	Simply More (HMO)	Miami-Dade		Miami-Dade	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefits	www.simplyhealthcareplans.com/medicare/prescription-drug-benefits
H5471	066	0	2021	01	Simply Complete (HMO D-SNP)	Polk		Polk	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefits	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5471	067	0	2021	01	Simply Care (HMO I-SNP)	Miami-Dade		Miami-Dade	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	068	0	2021	01	Simply Comfort (HMO I-SNP)	Miami-Dade		Miami-Dade	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	069	0	2021	01	Simply Level (HMO C-SNP)	Miami-Dade		Miami-Dade	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	070	0	2021	01	Simply Level (HMO C-SNP)	Polk		Polk	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	071	0	2021	01	Simply More (HMO)	Polk		Polk	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	072	0	2021	01	Simply Complete (HMO D-SNP)	Orange, Osceola, Seminole		Orange, Osceola, Seminole	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	073	0	2021	01	Simply Level (HMO C-SNP)	Orange, Osceola, Seminole		Orange, Osceola, Seminole	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	074	0	2021	01	Simply More (HMO)	Orange, Osceola, Seminole		Orange, Osceola, Seminole	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	075	0	2021	01	Simply Level (HMO C-SNP)	Hernando, Hillsborough, Pasco, Pinellas		Hernando, Hillsborough, Pasco, Pinellas	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	076	0	2021	01	Simply Complete (HMO D-SNP)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	077	0	2021	01	Simply More (HMO)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5471	078	0	2021	01	Simply More (HMO)	Hernando, Hillsborough, Pasco, Pinellas		Hernando, Hillsborough, Pasco, Pinellas	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	079	0	2021	01	Simply Care (HMO I-SNP)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	080	0	2021	01	Simply Level (HMO C-SNP)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	081	0	2021	01	Simply Comfort (HMO I-SNP)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	082	0	2021	01	Simply Complete (HMO D-SNP)	Hernando, Hillsborough, Pasco, Pinellas		Hernando, Hillsborough, Pasco, Pinellas	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	083	0	2021	01	Simply More (HMO)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5471	084	0	2021	01	Simply Complete (HMO D-SNP)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	085	0	2021	01	Simply Level (HMO C-SNP)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	090	0	2021	01	Simply Care (HMO I-SNP)	Polk		Polk	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	091	0	2021	01	Simply Comfort (HMO I-SNP)	Polk		Polk	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	092	0	2021	01	Simply Care (HMO I-SNP)	Orange, Osceola, Seminole		Orange, Osceola, Seminole	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	093	0	2021	01	Simply Comfort (HMO I-SNP)	Orange, Osceola, Seminole		Orange, Osceola, Seminole	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	094	0	2021	01	Simply Care (HMO I-SNP)	Hernando, Hillsborough, Pasco, Pinellas		Hernando, Hillsborough, Pasco, Pinellas	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	095	0	2021	01	Simply Comfort (HMO I-SNP)	Hernando, Hillsborough, Pasco, Pinellas		Hernando, Hillsborough, Pasco, Pinellas	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	096	0	2021	01	Simply Care (HMO I-SNP)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	097	0	2021	01	Simply Comfort (HMO I-SNP)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	098	0	2021	01	Simply Select (HMO)	Orange, Osceola, Seminole		Orange, Osceola, Seminole	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	099	0	2021	01	Simply Select (HMO)	Hernando, Hillsborough, Pasco, Pinellas		Hernando, Hillsborough, Pasco, Pinellas	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	100	0	2021	01	Simply Select (HMO)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	101	0	2021	01	Simply Select (HMO)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	http://www.simplyhealthcareplans.com/medicare/pharmacy/pharmacy-locator/index.html	http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html
H5471	103	0	2021	01	Simply Extra (HMO)	Miami-Dade		Miami-Dade	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5471	104	0	2021	01	Simply Extra (HMO)	Broward		Broward	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5471	105	0	2021	01	Simply Extra (HMO)	Palm Beach		Palm Beach	1	0	0	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	9250 W Flagler Street	Suite 600	Miami	FL	33174		Info@simplyhealthcareplans.com	Info@simplyhealthcareplans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.simplyhealthcareplans.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.mysimplymedicare.com	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies	www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies
H5475	001	0	2021	02	WellCare Extra Plus (HMO-POS D-SNP)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	003	0	2021	02	WellCare Elite (HMO-POS)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	004	0	2021	02	WellCare Extra Plus (HMO-POS D-SNP)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	005	0	2021	02	WellCare Essential (HMO-POS)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	006	0	2021	02	WellCare Essential (HMO-POS)	Select counties in MI/IL		Select counties in MI/IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	010	0	2021	02	WellCare Extra Plus (HMO-POS D-SNP)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	011	0	2021	02	WellCare Essential (HMO-POS)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	019	0	2021	02	WellCare Essential (HMO-POS)	Select counties in IN		Select counties in IN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	021	0	2021	02	WellCare Extra Plus (HMO-POS D-SNP)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	022	0	2021	02	WellCare Essential (HMO-POS)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	024	0	2021	02	WellCare Elite Smile (HMO-POS)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	026	0	2021	02	WellCare Explore (HMO-POS)	Select counties in MI/IL		Select counties in MI/IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	029	0	2021	02	WellCare Guardian (HMO-POS C-SNP)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	4	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	030	0	2021	02	WellCare Extra Plus (HMO-POS D-SNP)	Select counties in IN		Select counties in IN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	031	0	2021	01	WellCare Dividend (HMO)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	032	0	2021	01	WellCare Dividend (HMO)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	033	0	2021	01	WellCare Exclusive (HMO)	Select counties in MI		Select counties in MI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	034	0	2021	01	WellCare Exclusive (HMO)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	035	0	2021	02	WellCare Extra Plus (HMO-POS D-SNP)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	1	3	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	036	0	2021	02	WellCare Essential (HMO-POS)	Select counties in OH		Select counties in OH	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5475	037	0	2021	02	WellCare Essential (HMO-POS)	Select counties in IN		Select counties in IN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5493	001	0	2021	20	LIFE at St. Francis Healthcare, Inc (PACE)	New Castle County, Delaware		New Castle County, Delaware	1	3	0									1072 Justison Street		Wilmington	DE	19801		mmiller3@che-east.org	kguglielmo@che-east.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.saintfrancislife.org	0	0	1			0					3	0	0		www.carekinesis.com/	www.stfrancishealthcare.org
H5493	002	0	2021	20	LIFE at St. Francis Healthcare, Inc (PACE)	New Castle County, Delaware		New Castle County, Delaware	1	3	0									1072 Justison Street		Wilmington	DE	19801		mmiller3@che-east.org	kguglielmo@che-east.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.stfrancishealthcare.org	0	0	1			0					3	0	0		www.stfrancishealthcare.org	www.stfrancishealthcare.org
H5496	005	0	2021	01	Imperial Senior Value (HMO C-SNP)	Northern, Central and Southern California	Imperial Senior Value (HMO C-SNP)	Northern, Central and Southern California	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	1	4	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H5496	007	0	2021	01	Imperial Traditional (HMO)	Northern, Central and Southern California	Imperial Traditional (HMO)	Northern, Central and Southern California	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H5496	009	0	2021	01	Imperial Traditional Plus (HMO)	Northern, Central and Southern California	Imperial Traditional Plus (HMO)	Northern, Central and Southern California	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H5496	011	0	2021	01	Imperial Dual Plan (HMO D-SNP)	Sacramento and San Francisco	Imperial Dual Plan (HMO D-SNP)	Sacramento and San Francisco	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H5496	012	0	2021	01	Imperial Dynamic Plan (HMO)	SoCal and Sacramento	Imperial Dynamic Plan (HMO)	SoCal and Sacramento	1	0	0	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	1100 East Green Street		Pasadena	CA	91106		Enrollmentunit@imperialhealthplan.com	Members@imperialhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.imperialhealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.imperialhealthplan.com	www.imperialhealthplan.com	www.imperialhealthplan.com
H5521	012	0	2021	04	Aetna Medicare Premier Plus (PPO)	Central and Northeast Pennsylvania		Central and Northeast Pennsylvania	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	013	0	2021	04	Aetna Medicare Explorer Premier Plan (PPO)	Connecticut		Connecticut	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	015	0	2021	04	Aetna Medicare Premier Plan (PPO)	District of Columbia		District of Columbia	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	016	0	2021	04	Aetna Medicare Premier Plus (PPO)	Chicagoland		Chicagoland	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	020	0	2021	04	Aetna Medicare Premier 2 (PPO)	Select Counties in OH & KY		Select Counties in OH & KY	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	022	0	2021	04	Aetna Medicare Select Plan (PPO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	027	0	2021	04	Aetna Medicare Choice Plan (PPO)	Fairfax County and Surrounding Area		Fairfax County and Surrounding Area	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	033	0	2021	04	Aetna Medicare Premier (PPO)	North, Central, West, NW, SW, TC, South FL		North, Central, West, NW, SW, TC, South FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	037	0	2021	04	Aetna Medicare Explorer Premier (PPO)	Counties: BR, ES, HD, MR, MX, MN, MO, ON, PS, UN		Counties: BR, ES, HD, MR, MX, MN, MO, ON, PS, UN	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	040	0	2021	04	Aetna Medicare Premier Plan (PPO)	Metro Area: NYC, Queens, Brooklyn, SI, Nassau		Metro Area: NYC, Queens, Brooklyn, SI, Nassau	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	053	0	2021	04	Aetna Medicare Choice Plan (PPO)	San Diego County		San Diego County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	055	0	2021	04	Aetna Medicare Choice Plan (PPO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	056	0	2021	04	Aetna Medicare Choice Plan (PPO)	Orange County		Orange County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	057	0	2021	04	Aetna Medicare Prime (PPO)	Denver Metro		Denver Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	076	0	2021	04	Aetna Medicare Premier Plan (PPO)	Greater Rochester Area		Greater Rochester Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	077	0	2021	04	Aetna Medicare Premier Plan (PPO)	Northern Central Upstate New York		Northern Central Upstate New York	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	081	0	2021	04	Aetna Medicare Premier Plan (PPO)	North Carolina		North Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	082	0	2021	04	Aetna Medicare Essential Plan (PPO)	Richmond and Surrounding Area		Richmond and Surrounding Area	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	083	0	2021	04	Aetna Medicare Essential Plan (PPO)	Danville City and Surrounding Area		Danville City and Surrounding Area	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	084	0	2021	04	Aetna Medicare Essential Plan (PPO)	Newport News and Surrounding Area		Newport News and Surrounding Area	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	085	0	2021	04	Aetna Medicare Value Plan (PPO)	Northern Kentucky Area		Northern Kentucky Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	086	0	2021	04	Aetna Medicare Value (PPO)	Chicagoland		Chicagoland	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	087	0	2021	04	Aetna Medicare Value Plan (PPO)	Cincinnati Area		Cincinnati Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	088	0	2021	04	Aetna Medicare Value Plan (PPO)	Cleveland and Toledo Area		Cleveland and Toledo Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	089	0	2021	04	Aetna Medicare Value Plan (PPO)	Central Ohio Area		Central Ohio Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	090	0	2021	04	Aetna Medicare Value Plan (PPO)	Dayton Area		Dayton Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	091	0	2021	04	Aetna Medicare Essential Plan (PPO)	Atlanta GA and Southeast AL area		Atlanta GA and Southeast AL area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	095	0	2021	04	Aetna Medicare Premier Plus (PPO)	New Castle, Kent and Sussex Counties		New Castle, Kent and Sussex Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	099	0	2021	04	Aetna Medicare Value (PPO)	Northeast Indiana		Northeast Indiana	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	100	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Maricopa, Pima and Pinal Counties		Maricopa, Pima and Pinal Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	101	0	2021	04	Aetna Medicare Choice Plan (PPO)	Greater Salt Lake Metro		Greater Salt Lake Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	102	0	2021	04	Aetna Medicare Essential Plan (PPO)	Roanoke and Surrounding Area		Roanoke and Surrounding Area	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	110	0	2021	04	Aetna Medicare Premier Plan (PPO)	Capital Region and Hudson Valley Area		Capital Region and Hudson Valley Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	116	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Southwest Alabama		Southwest Alabama	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	117	0	2021	04	Aetna Medicare Premier Plan (PPO)	Suffolk County		Suffolk County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	118	0	2021	04	Aetna Medicare Elite Plan (PPO)	Greater Rochester Area		Greater Rochester Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	119	0	2021	04	Aetna Medicare Elite Plan (PPO)	Capital Region and Hudson Valley Area		Capital Region and Hudson Valley Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	120	0	2021	04	Aetna Medicare Elite Plan (PPO)	Metro Area: LI, 5 Boroughs, Westchester/Rockland		Metro Area: LI, 5 Boroughs, Westchester/Rockland	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	121	0	2021	04	Aetna Medicare Premier Plan (PPO)	Westchester, Rockland, Bronx Counties		Westchester, Rockland, Bronx Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	122	0	2021	04	Aetna Medicare Gold Plan (PPO)	Pennsylvania		Pennsylvania	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	123	0	2021	04	Aetna Medicare SNJ Prime Elite (PPO)	SNJ Counties: AL, BR, CM, CP, CU, GL, ON, SM		SNJ Counties: AL, BR, CM, CP, CU, GL, ON, SM	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	124	0	2021	04	Aetna Medicare Explorer Premier 2 (PPO)	SNJ Counties: ATL, BUR, CAM, CPM, CUM, GLO, SLM		SNJ Counties: ATL, BUR, CAM, CPM, CUM, GLO, SLM	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	125	0	2021	04	Aetna Medicare Choice Plan (PPO)	Los Angeles County		Los Angeles County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	127	0	2021	04	Aetna Medicare Choice Plan (PPO)	Puget Sound		Puget Sound	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	128	0	2021	04	Aetna Medicare Select Plan (PPO)	Puget Sound		Puget Sound	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	134	0	2021	04	Aetna Medicare Premier 1 (PPO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	139	0	2021	04	Aetna Medicare Value Plan (PPO)	North Carolina		North Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	140	0	2021	04	Aetna Medicare Premier Plan (PPO)	Greenville/Spartanburg SC and Surrounding Area		Greenville/Spartanburg SC and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	141	0	2021	04	Aetna Medicare Premier Plan (PPO)	Nashville TN and Surrounding Area		Nashville TN and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	142	0	2021	04	Aetna Medicare Explorer Plan (PPO)	Southern Maine		Southern Maine	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	143	0	2021	04	Aetna Medicare Explorer Plan (PPO)	Mid Maine		Mid Maine	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	144	0	2021	04	Aetna Medicare Explorer Plan (PPO)	Northern and Additional Maine		Northern and Additional Maine	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	150	0	2021	04	Aetna Medicare Premier (PPO)	Milwaukee Metropolitan Area		Milwaukee Metropolitan Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	154	0	2021	04	Aetna Medicare Premier Plan (PPO)	Memphis TN and Surrounding Area		Memphis TN and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	156	0	2021	04	Aetna Medicare Value Plan (PPO)	Lexington Area		Lexington Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	157	0	2021	04	Aetna Medicare Elite Plan (PPO)	Connecticut		Connecticut	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	159	0	2021	04	Aetna Medicare Explorer Plan (PPO)	Eastern Massachusetts		Eastern Massachusetts	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	160	0	2021	04	Aetna Medicare Explorer Plan (PPO)	Central Massachusetts		Central Massachusetts	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	168	0	2021	04	Aetna Medicare Essential Plan (PPO)	Wake and Durham Counties NC		Wake and Durham Counties NC	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	169	0	2021	04	Aetna Medicare Value Plan (PPO)	Sandhills and Southeastern NC		Sandhills and Southeastern NC	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	170	0	2021	04	Aetna Medicare Premier Plus Plan (PPO)	Greensboro, Winston-Salem NC and Surrounding Area		Greensboro, Winston-Salem NC and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	171	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Central Alabama		Central Alabama	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	177	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Cherokee County		Cherokee County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	178	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	184	0	2021	04	Aetna Medicare Platinum Plan (PPO)	Maricopa, Pima and Pinal Counties		Maricopa, Pima and Pinal Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	187	0	2021	04	Aetna Medicare Premier (PPO)	Denver Metro		Denver Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	190	0	2021	04	Aetna Medicare Premier (PPO)	Northeast Indiana		Northeast Indiana	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	194	0	2021	04	Aetna Medicare Premier (PPO)	Southwest Michigan		Southwest Michigan	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	195	0	2021	04	Aetna Medicare Value (PPO)	Milwaukee Metropolitan Area		Milwaukee Metropolitan Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	196	0	2021	04	Aetna Medicare Choice Plan (PPO)	Southern Utah		Southern Utah	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	197	0	2021	04	Aetna Medicare Value Plan (PPO)	Northern Utah		Northern Utah	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	200	0	2021	04	Aetna Medicare Platinum Plan (PPO)	CHS, CNO, GLA, GHM, MHV, SCZ, YVP and YMA		CHS, CNO, GLA, GHM, MHV, SCZ, YVP and YMA	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	205	0	2021	04	Aetna Medicare Choice Plan (PPO)	Kern County		Kern County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	206	0	2021	04	Aetna Medicare Choice Plan (PPO)	Fresno County		Fresno County	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	207	0	2021	04	Aetna Medicare Prime (PPO)	Southern Colorado		Southern Colorado	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	211	0	2021	04	Aetna Medicare Value (PPO)	Southwest Indiana		Southwest Indiana	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	212	0	2021	04	Aetna Medicare Elite Plan (PPO)	Western New York		Western New York	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	214	0	2021	04	Aetna Medicare Value (PPO)	Southeast Michigan		Southeast Michigan	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	215	0	2021	04	Aetna Medicare Premier Plan (PPO)	Western New York		Western New York	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	216	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Tuscaloosa and Surrounding Counties		Tuscaloosa and Surrounding Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	217	0	2021	04	Aetna Medicare Premier Plus (PPO)	Southeast Michigan		Southeast Michigan	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	218	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Northern Mississippi		Northern Mississippi	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	219	0	2021	04	Aetna Medicare Value (PPO)	Southwest Michigan		Southwest Michigan	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	220	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Southern Mississippi		Southern Mississippi	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	221	0	2021	04	Aetna Medicare Explorer Premier Plan (PPO)	Massachusetts		Massachusetts	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	222	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Southeast Alabama		Southeast Alabama	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	223	0	2021	04	Aetna Medicare Value (PPO)	Northwest Indiana		Northwest Indiana	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	224	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Montgomery and Surrounding Counties		Montgomery and Surrounding Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	226	0	2021	04	Aetna Medicare Premier (PPO)	Northwest Indiana		Northwest Indiana	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	227	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Northern Alabama		Northern Alabama	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	228	0	2021	04	Aetna Medicare Explorer Value (PPO)	Northern/Northwestern Illinois		Northern/Northwestern Illinois	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	229	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Select Alabama Counties		Select Alabama Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	230	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Monroe Metro and Surrounding Parishes		Monroe Metro and Surrounding Parishes	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	231	0	2021	04	Aetna Medicare Value (PPO)	Central Indiana		Central Indiana	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	232	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Alexandria Metro and Surrounding Parishes		Alexandria Metro and Surrounding Parishes	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	233	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Lake Charles Metro and Surrounding Parishes		Lake Charles Metro and Surrounding Parishes	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	234	0	2021	04	Aetna Medicare Freedom Plan (PPO)	Lafayette Metro and Surrounding Parishes		Lafayette Metro and Surrounding Parishes	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	235	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	236	0	2021	04	Aetna Medicare Premier Plan (PPO)	Western North Carolina		Western North Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	237	0	2021	04	Aetna Medicare Choice Plan (PPO)	Southwest Washington		Southwest Washington	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	239	0	2021	04	Aetna Medicare Value Plan (PPO)	Western North Carolina		Western North Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	241	0	2021	04	Aetna Medicare Eagle Plan (PPO)	North Carolina		North Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	243	0	2021	04	Aetna Medicare Value Plan (PPO)	Rocky Mount North Carolina		Rocky Mount North Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	244	0	2021	04	Aetna Medicare Select Plan (PPO)	Southwest Washington		Southwest Washington	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	245	0	2021	04	Aetna Medicare Premier Plan (PPO)	Columbia Metro South Carolina		Columbia Metro South Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	246	0	2021	04	Aetna Medicare Elite Plan (PPO)	Greater Salt Lake Metro Area		Greater Salt Lake Metro Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	247	0	2021	04	Aetna Medicare Premier Plan (PPO)	Charleston and Surrounding Area South Carolina		Charleston and Surrounding Area South Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	249	0	2021	04	Aetna Medicare Premier Plan (PPO)	Pee Dee South Carolina		Pee Dee South Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	250	0	2021	04	Aetna Medicare Prime 1 (PPO)	Denver Metro		Denver Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	251	0	2021	04	Aetna Medicare Value Plan (PPO)	Midlands South Carolina		Midlands South Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	252	0	2021	04	Aetna Medicare Value Plan (PPO)	Hilton Head, Augusta and Surrounding Area SC		Hilton Head, Augusta and Surrounding Area SC	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	253	0	2021	04	Aetna Medicare Elite Plan (PPO)	Hilton Head SC and Surrounding Area		Hilton Head SC and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	254	0	2021	04	Aetna Medicare Premier Plan (PPO)	Middle Tennessee		Middle Tennessee	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	259	0	2021	04	Aetna Medicare Value Plan (PPO)	Louisville Area		Louisville Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	260	0	2021	04	Aetna Medicare Value Plan (PPO)	Bowling Green/Southwest KY Area		Bowling Green/Southwest KY Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	261	0	2021	04	Aetna Medicare Value (PPO)	Western Pennsylvania		Western Pennsylvania	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	262	0	2021	04	Aetna Medicare Value (PPO)	New Castle, Kent and Sussex Counties		New Castle, Kent and Sussex Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	263	0	2021	04	Aetna Medicare Value (PPO)	Central and Eastern Pennsylvania		Central and Eastern Pennsylvania	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	266	0	2021	04	Aetna Medicare Value Plan (PPO)	Ashland Area		Ashland Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	267	0	2021	04	Aetna Medicare Value Plan (PPO)	Eastern Kentucky Area		Eastern Kentucky Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	268	0	2021	04	Aetna Medicare Premier Plus (PPO)	Central FL		Central FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	269	0	2021	04	Aetna Medicare Premier Plus (PPO)	North FL		North FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	270	0	2021	04	Aetna Medicare Premier Plus (PPO)	West FL		West FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	271	0	2021	04	Aetna Medicare Premier Plus (PPO)	Central FL, North FL		Central FL, North FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	272	0	2021	04	Aetna Medicare Premier Plus (PPO)	Southwest FL		Southwest FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	273	0	2021	04	Aetna Medicare Premier Plus (PPO)	South FL, Treasure Coast FL		South FL, Treasure Coast FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	275	0	2021	04	Aetna Medicare Prime Premier (PPO)	Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR		Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	277	0	2021	04	Aetna Medicare Prime Credit (PPO)	Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR		Counties: BR, HT, MR, MN, MO, PS, SM, SX, UN, WR	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	278	0	2021	04	Aetna Medicare Explorer Premier Plus (PPO)	Northern and Southern NJ		Northern and Southern NJ	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	279	0	2021	04	Aetna Medicare Eagle Plan (PPO)	South Carolina		South Carolina	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	280	0	2021	04	Aetna Medicare Premier Plan (PPO)	Chattanooga TN and Surrounding Area		Chattanooga TN and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	281	0	2021	04	Aetna Medicare Value Plan (PPO)	Chattanooga TN and Surrounding Area		Chattanooga TN and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	282	0	2021	04	Aetna Medicare Premier (PPO)	Green Bay Metro		Green Bay Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	283	0	2021	04	Aetna Medicare Value (PPO)	Green Bay Metro		Green Bay Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	284	0	2021	04	Aetna Medicare Premier (PPO)	Northwest Michigan		Northwest Michigan	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	285	0	2021	04	Aetna Medicare Value (PPO)	Northwest Michigan		Northwest Michigan	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	286	0	2021	04	Aetna Medicare Eagle (PPO)	IL, IN, MI, WI		IL, IN, MI, WI	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com	www.aetnamedicare.com
H5521	288	0	2021	04	Aetna Medicare Value (PPO)	Midland Area		Midland Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	289	0	2021	04	Aetna Medicare Value (PPO)	Green and Rock Counties		Green and Rock Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	290	0	2021	04	Aetna Medicare Elite Plan (PPO)	Mohave and Yavapai Counties		Mohave and Yavapai Counties	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	292	0	2021	04	Aetna Medicare Choice Plan (PPO)	Ventura County		Ventura County	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	293	0	2021	04	Aetna Medicare Elite Plan (PPO)	Northern California		Northern California	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	294	0	2021	04	Aetna Medicare St. Luke's Prime Plan (PPO)	Allentown Metro Area		Allentown Metro Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	295	0	2021	04	Aetna Medicare Explorer Elite (PPO)	NNJ West Counties: HUT, SOM, SUX, WAR		NNJ West Counties: HUT, SOM, SUX, WAR	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	296	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Massachusetts		Massachusetts	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	298	0	2021	04	Aetna Medicare Explorer Premier (PPO)	NNJ West Counties: HUT, SOM, SUX, WAR		NNJ West Counties: HUT, SOM, SUX, WAR	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	299	0	2021	04	Aetna Medicare Elite Plan (PPO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	300	0	2021	04	Aetna Medicare Select Plan (PPO)	Northern Nevada		Northern Nevada	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	301	0	2021	04	Aetna Medicare Choice Plan (PPO)	Northern Nevada		Northern Nevada	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/formulary	www.aetnamedicare.com/formulary
H5521	302	0	2021	04	Aetna Medicare Premier (PPO)	Indianapolis and Central Indiana area		Indianapolis and Central Indiana area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	303	0	2021	04	Aetna Medicare Elite Plan (PPO)	Northern Nevada		Northern Nevada	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/formulary	www.aetnamedicare.com/formulary
H5521	304	0	2021	04	Aetna Medicare Premier (PPO)	Evansville and Southwest Indiana area		Evansville and Southwest Indiana area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	305	0	2021	04	Aetna Medicare Premier Plus (PPO)	Panhandle/Northwest FL		Panhandle/Northwest FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com	PO Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	306	0	2021	04	Aetna Medicare Eagle (PPO)	Southwest FL		Southwest FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	307	0	2021	04	Aetna Medicare Premier (PPO)	Upper Peninsula Michigan area		Upper Peninsula Michigan area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamdicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	308	0	2021	04	Aetna Medicare Eagle (PPO)	West FL		West FL	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	hicksjs@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	309	0	2021	04	Aetna Medicare Elite Plan 2 (PPO)	Westchester, Rockland, Bronx Counties		Westchester, Rockland, Bronx Counties	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	310	0	2021	04	Aetna Medicare Elite Plan 3 (PPO)	Metro Area: Brooklyn, NYC, Queens, Staten Island		Metro Area: Brooklyn, NYC, Queens, Staten Island	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	311	0	2021	04	Aetna Medicare Value (PPO)	Upper Peninsula Michigan area		Upper Peninsula Michigan area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	312	0	2021	04	Aetna Medicare Value Plan (PPO)	Metro Area: Brooklyn, NYC, Queens		Metro Area: Brooklyn, NYC, Queens	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	313	0	2021	04	Aetna Medicare Credit Plan (PPO)	Upstate NY Area: HV, Capital, CNY, Rochester, WNY		Upstate NY Area: HV, Capital, CNY, Rochester, WNY	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	314	0	2021	04	Aetna Medicare DMG Prime (PPO)	Chicagoland		Chicagoland	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	318	0	2021	04	Aetna Medicare Value Plan (PPO)	Greater Rochester Area		Greater Rochester Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	319	0	2021	04	Aetna Medicare Premier Plus Plan (PPO)	Greenville/Spartanburg SC and Surrounding Area		Greenville/Spartanburg SC and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	320	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Metro Area: LI, 5 Boroughs, Westchester/Rockland		Metro Area: LI, 5 Boroughs, Westchester/Rockland	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	321	0	2021	04	Aetna Medicare Premier Plus Plan (PPO)	Nashville TN and Surrounding Area		Nashville TN and Surrounding Area	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	322	0	2021	04	Aetna Medicare Eagle (PPO)	Newport News and Surrounding Area		Newport News and Surrounding Area	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
H5521	323	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Upstate NY Area: HV, Capital, CNY, Rochester, WNY		Upstate NY Area: HV, Capital, CNY, Rochester, WNY	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	324	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Mississippi		Mississippi	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	326	0	2021	04	Aetna Medicare Value Plus Plan (PPO)	New Orleans		New Orleans	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/formulary
H5521	328	0	2021	04	Aetna Medicare Value Plus Plan (PPO)	Atlanta Metro		Atlanta Metro	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	329	0	2021	04	Aetna Medicare Eagle Plan (PPO)	MCP, MHV, PMA, PIN, YVP		MCP, MHV, PMA, PIN, YVP	1	0	0	PO Box  14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	330	0	2021	04	Aetna Medicare Eagle Plan (PPO)	Puget Sound		Puget Sound	1	0	0	P.O. Box 14088		Lexington	KY	40512		GoldenMedicare@aetna.com	HicksJS@aetna.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	801	0	2021	04	Aetna Medicare Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	802	0	2021	04	Aetna Medicare Plan w/Rx (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	805	0	2021	04	Aetna Medicare Part B Only Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	806	0	2021	04	Aetna Medicare Part B Only Plan w/Rx (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	809	0	2021	04	Aetna Medicare $10 Buy-Down Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	810	0	2021	04	Aetna Medicare $10 Buy-Down Plan w/Rx (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	812	0	2021	04	Aetna Medicare $75 Buy-Down w/Rx Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	814	0	2021	04	Aetna Medicare Part B Only $10 Buy-Down Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	815	0	2021	04	Aetna Medicare Part B Only $10 Buy-Down Plan w/Rx (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	816	0	2021	04	Aetna Medicare Part B Only $75 Buy-Down Plan w/Rx (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	817	0	2021	04	Aetna Medicare $75 Buy-Down Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5521	818	0	2021	04	Aetna Medicare Part B Only $75 Buy-Down Plan (PPO)	National		National	1	3	1	151 Farmington Avenue		Hartford	CT	06156												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	001	0	2021	04	Aetna Medicare Advantra Premier Plus (PPO)	Allegheny County		Allegheny County	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	002	0	2021	04	Aetna Medicare Advantra Premier Plus (PPO)	Central Pennsylvania		Central Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	004	0	2021	04	Aetna Medicare Advantra Silver (PPO)	Central Pennsylvania		Central Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	005	0	2021	04	Aetna Medicare Advantra Silver (PPO)	Western Pennsylvania		Western Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	013	0	2021	04	Aetna Medicare Advantra Silver Plus (PPO)	Central Pennsylvania		Central Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	014	0	2021	04	Aetna Medicare Advantra Premier Plus (PPO)	Southeastern Pennsylvania		Southeastern Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	017	0	2021	04	Aetna Medicare Advantra Credit Value (PPO)	Pennsylvania		Pennsylvania	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	018	0	2021	04	Aetna Medicare Advantra Premier (PPO)	Allegheny		Allegheny	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	802	0	2021	04	Aetna Medicare Plan (PPO)	Pennsylvania		Pennsylvania	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002000000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5522	803	0	2021	04	Aetna Medicare Plan w/Rx (PPO)	Pennsylvania		Pennsylvania	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5525	004	0	2021	04	HumanaChoice H5525-004 (PPO)	Peoria Illinois area		Peoria Illinois area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	005	0	2021	04	HumanaChoice H5525-005 (PPO)	Greater Philadelphia Metro Area		Greater Philadelphia Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	006	0	2021	04	HumanaChoice H5525-006 (PPO)	South Central Pennsylvania area		South Central Pennsylvania area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	007	0	2021	04	HumanaChoice H5525-007 (PPO)	North Central Pennsylvania area		North Central Pennsylvania area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	008	0	2021	04	HumanaChoice H5525-008 (PPO)	Select counties in Suburban Indiana		Select counties in Suburban Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $220.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $220.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	015	0	2021	04	HumanaChoice H5525-015 (PPO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	017	0	2021	04	HumanaChoice H5525-017 (PPO)	Western Pennsylvania Area		Western Pennsylvania Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	020	0	2021	04	HumanaChoice H5525-020 (PPO)	Mobile Metro Area		Mobile Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	022	0	2021	04	HumanaChoice H5525-022 (PPO)	Select counties in Kentucky		Select counties in Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	023	0	2021	04	HumanaChoice H5525-023 (PPO)	Select counties in West Virginia		Select counties in West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	024	0	2021	04	HumanaChoice H5525-024 (PPO)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	026	0	2021	04	HumanaChoice H5525-026 (PPO)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	027	0	2021	04	HumanaChoice H5525-027 (PPO)	Select Counties in Montana		Select Counties in Montana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	030	0	2021	04	HumanaChoice H5525-030 (PPO)	Select Counties in Ohio and Kentucky		Select Counties in Ohio and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	031	0	2021	04	Humana Honor (PPO)	Select Counties in Montana		Select Counties in Montana	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	034	0	2021	04	HumanaChoice H5525-034 (PPO)	Wilmington Area		Wilmington Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	035	0	2021	04	HumanaChoice H5525-035 (PPO)	Select Counties in North Carolina		Select Counties in North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	036	0	2021	04	HumanaChoice SNP-DE H5525-036 (PPO D-SNP)	Greater North Carolina Area		Greater North Carolina Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	037	0	2021	04	Humana Value Plus H5525-037 (PPO)	Select Louisiana Parishes		Select Louisiana Parishes	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	038	0	2021	04	HumanaChoice H5525-038 (PPO)	Pennsylvania		Pennsylvania	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	039	0	2021	04	Humana Value Plus H5525-039 (PPO)	Pennsylvania		Pennsylvania	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	040	0	2021	04	Humana Value Plus H5525-040 (PPO)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	041	0	2021	04	Humana Value Plus H5525-041 (PPO)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	042	0	2021	04	HumanaChoice H5525-042 (PPO)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	044	0	2021	04	HumanaChoice H5525-044 (PPO)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	045	0	2021	04	HumanaChoice SNP-DE H5525-045 (PPO D-SNP)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	046	0	2021	04	HumanaChoice SNP-DE H5525-046 (PPO D-SNP)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	047	0	2021	04	HumanaChoice H5525-047 (PPO)	Select Counties in Pennsylvania		Select Counties in Pennsylvania	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	048	0	2021	04	HumanaChoice SNP-DE H5525-048 (PPO D-SNP)	Select counties in Indiana		Select counties in Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $425.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $425.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	049	0	2021	04	HumanaChoice H5525-049 (PPO)	Eastern North Carolina		Eastern North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	809	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	810	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	812	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	813	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	816	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	817	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	818	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	819	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	820	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5525	821	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5526	004	0	2021	04	BlueCross BlueShield Forever Blue 751 (PPO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H5526	016	0	2021	04	BlueCross BlueShield Forever Blue Value (PPO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H5526	018	0	2021	04	BlueShield Forever Blue 770 (PPO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 15013		Albany	NY	12214		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	PO Box 15013		Albany	NY	12214		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H5526	020	0	2021	04	BlueCross BlueShield Freedom Nation (PPO)	Western New York		Western New York	1	0	0	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	PO Box 80		Buffalo	NY	14202		SalesCenterWNY@bcbswny.com	customerservice@bcbswny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbswny.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbswny.com/medicare	www.bcbswny.com/medicare	www.bcbswny.com/medicare
H5526	021	0	2021	04	BlueShield Freedom Nation (PPO)	Northeastern New York		Northeastern New York	1	0	0	PO Box 15013		Albany	NY	12214		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	PO Box 15013		Albany	NY	12214		SalesCenterNENY@bsneny.com	customerservice@bsneny.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bsneny.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $375.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $375.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bsneny.com/medicare	www.bsneny.com/medicare	www.bsneny.com/medicare
H5526	806	0	2021	04	PPO Group (MA Only) CY (PPO)	Western and Northeastern New York		Western and Northeastern New York	1	3	1	PO Box 80		Buffalo	NY	14202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nymedicare.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.nymedicare.com	www.bcbswny.com	http://www.bcbswny.com/pharmacy
H5526	808	0	2021	04	PPO Group (MA-PD) CY (PPO)	Western and Northeastern New York		Western and Northeastern New York	1	3	1	PO Box 80		Buffalo	NY	14202				PO Box 80		Buffalo	NY	14202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nymedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	1					3	0	0	www.nymedicare.com	www.bcbswny.com	http://www.bcbswny.com/pharmacy
H5528	807	0	2021	04	EmblemHealth Group Access Rx (PPO)	United States		United States	1	3	1	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.emblemhealth.com/our-plans/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0		www.emblemhealth.com	www.emblemhealth.com
H5528	815	0	2021	04	EmblemHealth Group Access Rx Carveout (PPO)	United States		United States	1	3	1	PO Box 4001		Farmington	CT	06034												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.emblemhealth.com/our-plans/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		www.emblemhealth.com	www.emblemhealth.com
H5533	003	0	2021	04	UPMC for Life PPO High Deductible with Rx (PPO)	Western Pennsylvania		Western Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1					3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5533	005	0	2021	04	UPMC for Life PPO Rx Enhanced (PPO)	Western Pennsylvania		Western Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5533	007	0	2021	04	UPMC for Life PPO Rx Enhanced (PPO)	Berks County		Berks County	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5533	008	0	2021	04	UPMC for Life PPO Rx Enhanced (PPO)	South Central PA		South Central PA	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5533	801	0	2021	04	UPMC Employer Group (PPO)	Western Pennsylvania		Western Pennsylvania	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu									2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	2	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5533	802	0	2021	04	UPMC Employer Group Rx (PPO)	Western Pennsylvania		Western Pennsylvania	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1					3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5533	803	0	2021	04	UPMC Employer Group Rx (PPO)	Western Pennsylvania		Western Pennsylvania	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	1					3	0	0	www.upmchealthplan.com/medicare/	https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
H5549	003	0	2021	01	VNSNY CHOICE Total (HMO D-SNP)	New York Metro Area		New York Metro Area	1	0	0	220 East 42nd Street	3rd Floor	New York	NY	10017				220 East 42nd Street	3rd Floor	New York	NY	10017				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.vnsnychoice.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.vnsnychoice.org	http://www.vnsnychoice.org/	http://www.vnsnychoice.org/
H5576	008	0	2021	02	Vantage TRADITIONAL PLUS (HMO-POS)	State of Louisiana		State of Louisiana	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	017	1	2021	02	Vantage STANDARD (HMO-POS)	North, Central, and South LA		NE LA, EBR, SHEL, and TANG parishes	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	017	2	2021	02	Vantage STANDARD (HMO-POS)	North, Central, and South LA		North, Central, and South LA	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	018	1	2021	02	Vantage PREMIUM (HMO-POS)	North, Central, and South LA		NE LA, EBR, SHEL, and TANG parishes	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	018	2	2021	02	Vantage PREMIUM (HMO-POS)	North, Central, and South LA		North, Central, and South LA	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	019	0	2021	02	Vantage DUAL PLUS (HMO-POS D-SNP)	State of Louisiana		State of Louisiana	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	020	1	2021	02	Vantage BASIC (HMO-POS)	North, Central, and South LA		NE LA, EBR, SHEL, and TANG parishes	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	020	2	2021	02	Vantage BASIC (HMO-POS)	North, Central, and South LA		North, Central, and South LA	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	022	0	2021	02	Vantage 100 (HMO-POS)	Central and North Louisiana		Central and North Louisiana	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	801	0	2021	02	Vantage - MAPD Employer Calendar (HMO-POS)	Louisiana		Louisiana	1	3	1	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	802	0	2021	02	Vantage - MAPD Emp Non-Calendar (HMO-POS)	Louisiana		Louisiana	1	3	1	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5576	803	0	2021	02	Vantage - MA Employer Calendar (HMO-POS)	Louisiana		Louisiana	1	3	1	130 DeSiard St	Suite 300	Monroe	LA	71201												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H5577	002	0	2021	01	MCS Classicare Platino Ideal (HMO D-SNP)	Puerto Rico	MCS Classicare Platino Ideal (HMO D-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	005	0	2021	01	MCS Classicare Efectivo (HMO)	Puerto Rico	MCS Classicare Efectivo (HMO)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	008	0	2021	02	MCS Classicare Essential (HMO-POS)	Puerto Rico	MCS Classicare Essential (HMO-POS)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	014	0	2021	01	MCS Classicare MediCa$h (HMO)	Puerto Rico	MCS Classicare MediCa$h (HMO)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	016	0	2021	01	MCS Classicare MediOnlyNoRx (HMO)	Puerto Rico	MCS Classicare MediOnlyNoRx (HMO)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com									1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	017	0	2021	01	MCS Classicare Platino Progreso (HMO D-SNP)	Puerto Rico	MCS Classicare Platino Progreso (HMO D-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	028	0	2021	01	MCS Classicare Platino Clásico (HMO D-SNP)	Puerto Rico	MCS Classicare Platino Clásico (HMO D-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	029	0	2021	01	MCS Classicare Platino MásCa$h (HMO D-SNP)	Puerto Rico	MCS Classicare Platino MásCa$h (HMO D-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	031	0	2021	01	MCS Classicare Activo (HMO)	Puerto Rico	MCS Classicare Activo (HMO)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	036	0	2021	01	MCS Classicare Platino Recarga (HMO D-SNP)	Puerto Rico	MCS Classicare Platino Recarga (HMO D-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	037	0	2021	01	MCS Classicare Platino @Home (HMO D-SNP)	Puerto Rico	MCS Classicare Platino @Home (HMO D-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	3	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	038	0	2021	01	MCS Classicare Primero (HMO C-SNP)	Puerto Rico	MCS Classicare Primero (HMO C-SNP)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	1	4	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	039	0	2021	01	MCS Classicare SuperRx (HMO)	Puerto Rico	MCS Classicare SuperRx (HMO)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	040	0	2021	01	MCS Classicare AhorraRx (HMO)	Puerto Rico	MCS Classicare AhorraRx (HMO)	Puerto Rico	1	0	0	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	801	0	2021	01	MCS Classicare MA Group (HMO)	Puerto Rico	MCS Classicare MA Group (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com									1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	802	0	2021	01	MCS Classicare MA-PD Group (HMO)	Puerto Rico	MCS Classicare MA-PD Group (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	809	0	2021	01	MCS Classicare MA-PD Group 2nd Formulary Opt. (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2nd Formulary Opt. (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	816	0	2021	01	MCS Classicare MA-PD Group 2A (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2A (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	817	0	2021	01	MCS Classicare MA-PD Group 2B (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2B (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	818	0	2021	01	MCS Classicare MA-PD Group 2C (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2C (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	819	0	2021	01	MCS Classicare MA-PD Group 2D (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2D (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	820	0	2021	01	MCS Classicare MA-PD Group 2E (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2E (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	821	0	2021	01	MCS Classicare MA-PD Group 2F (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2F (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	822	0	2021	01	MCS Classicare MA-PD Group 2G (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2G (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	823	0	2021	01	MCS Classicare MA-PD Group 2H (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2H (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	824	0	2021	01	MCS Classicare MA-PD Group 2I (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2I (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	825	0	2021	01	MCS Classicare MA-PD Group 2J (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2J (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	826	0	2021	01	MCS Classicare MA-PD Group 2K (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2K (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	827	0	2021	01	MCS Classicare MA-PD Group 2L (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2L (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	828	0	2021	01	MCS Classicare MA-PD Group 2M (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2M (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	829	0	2021	01	MCS Classicare MA-PD Group 2N (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2N (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	830	0	2021	01	MCS Classicare MA-PD Group 2O (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2O (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5577	831	0	2021	01	MCS Classicare MA-PD Group 2P (HMO)	Puerto Rico	MCS Classicare MA-PD Group 2P (HMO)	Puerto Rico	1	3	1	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	MCS Advantage	PO Box 191720	San Juan	PR	00919			supervisorescustomercare@medicalcardsystem.com	1000000000208002000308002000408002000508002000608002000708001630	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mcsclassicare.com	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	www.mcsclassicare.com	www.mcsclassicare.com	www.mcsclassicare.com
H5580	001	0	2021	01	Mercy Care Advantage (HMO D-SNP)	Maricopa, Pinal, and Gila Counties	Mercy Care Advantage (HMO D-SNP)	Maricopa, Pinal, and Gila Counties	1	0	0	4755 S. 44th Place		Phoenix	AZ	85040				4755 S. 44th Place		Phoenix	AZ	85040				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.MercyCareAz.org	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.MercyCareAz.org	www.MercyCareAz.org	www.MercyCareAz.org
H5580	004	0	2021	01	Mercy Care Advantage (HMO D-SNP)	Maricopa, Gila, Pinal, and Pima Counties	Mercy Care Advantage (HMO D-SNP)	Maricopa, Gila, Pinal, and Pima Counties	1	0	0	4755 S. 44th Place		Phoenix	AZ	85040				4755 S. 44th Place		Phoenix	AZ	85040				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.MercyCareAz.org	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.MercyCareAz.org	www.MercyCareAz.org	www.MercyCareAz.org
H5580	005	0	2021	01	Mercy Care Advantage (HMO D-SNP)	Arizona Statewide	Mercy Care Advantage (HMO D-SNP)	Arizona Statewide	1	0	0	4755 S. 44th Place		Phoenix	AZ	85040				4755 S. 44th Place		Phoenix	AZ	85040				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.MercyCareAz.org	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.MercyCareAz.org	www.MercyCareAz.org	www.MercyCareAz.org
H5587	002	0	2021	01	Health Choice Pathway (HMO D-SNP)	Arizona: APA, CCN, GIL, MAR, MOH, NAV, PIN, YAV		Arizona: APA, CCN, GIL, MAR, MOH, NAV, PIN, YAV	1	0	0	410 N 44th Street	Suite 900	Phoenix	AZ	85008		comments@healthchoiceaz.com	comments@healthchoiceaz.com	410 N 44th Street	Suite 900	Phoenix	AZ	85008		comments@healthchoiceaz.com	comments@healthchoiceaz.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	https://www.healthchoicepathway.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.healthchoicepathway.com	https://www.healthchoicepathway.com/members/prescription-drug-information/	https://www.healthchoicepathway.com
H5590	004	0	2021	01	Allwell Medicare (HMO)	Yavapai and Yuma Counties		Yavapai and Yuma Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H5590	005	0	2021	01	Allwell Medicare Essentials (HMO)	Maricopa and Pinal counties		Maricopa and Pinal counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H5590	007	0	2021	01	Allwell Medicare Essentials I (HMO)	Cochise, Santa Cruz, Yuma counties		Cochise, Santa Cruz, Yuma counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H5590	008	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Central and Southern AZ Counties		Central and Southern AZ Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.azcompletehealth.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/findadoctor	allwell.azcompletehealth.com/formulary
H5591	001	0	2021	02	Martin's Point Generations Advantage Prime (HMO-POS)	Northern Maine & Northern New Hampshire		Northern Maine & Northern New Hampshire	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	003	0	2021	01	Martin's Point Generations Advantage Alliance (HMO)	All Maine & NH Counties		All Maine & NH Counties	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	005	0	2021	02	Martin's Point Generations Advantage Prime (HMO-POS)	Southern NH Counties		Southern NH Counties	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	006	1	2021	02	Martin's Point Generations Advantage Prime (HMO-POS)	Southern Maine: Andr, Cumb, Kenn, Saga, York		Cumberland County	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	006	2	2021	02	Martin's Point Generations Advantage Prime (HMO-POS)	Southern Maine: Andr, Cumb, Kenn, Saga, York		Androscoggin, Kennebec & Sagadahoc Counties	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	006	4	2021	02	Martin's Point Generations Advantage Prime (HMO-POS)	Southern Maine: Andr, Cumb, Kenn, Saga, York		York County	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	007	0	2021	01	Martin's Point Generations Advantage Focus DC (HMO C-SNP)	Cumberland County		Cumberland County	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	1	4	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	009	0	2021	01	Martin's Point Generations Advantage Value Plus (HMO)	Northern, Central, and Midcoast Maine		Northern, Central, and Midcoast Maine	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	013	0	2021	01	Martin's Point Generations Advantage Value Plus (HMO)	ME: Andro, Kenn, Saga, York & NH: Hills, Strafford		ME: Andro, Kenn, Saga, York & NH: Hills, Strafford	1	0	0	PO Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	PO Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	801	0	2021	02	Martin's Point Generations Advantage Prime Group (HMO-POS)	National		National	1	3	1	P.O. Box 9746	331 Veranda Street	Portland	ME	04104				P.O. Box 9746	331 Veranda Street	Portland	ME	04104				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5591	802	0	2021	02	Martin's Point Generations Advantage Prime Group (HMO-POS)	National		National	1	3	1	P.O. Box 9746	331 Veranda Street	Portland	ME	04104				P.O. Box 9746	331 Veranda Street	Portland	ME	04104				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
H5593	001	0	2021	01	Aetna Medicare Assure Premier (HMO D-SNP)	Partial state of Iowa		Partial state of Iowa	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5593	801	0	2021	01	Aetna Medicare Plan (HMO)	Iowa		Iowa	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5593	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Iowa		Iowa	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5594	001	0	2021	01	Optimum Gold Rewards Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	002	0	2021	01	Optimum Platinum Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	016	0	2021	01	Optimum Emerald Partial (HMO D-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	017	0	2021	01	Optimum Emerald Full (HMO D-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	019	0	2021	01	Optimum Platinum Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	022	0	2021	01	Optimum Gold Rewards Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	026	0	2021	01	Optimum Gold Rewards Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	028	0	2021	01	Optimum Diamond Rewards (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	029	0	2021	01	Optimum Diamond Rewards COPD (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	030	0	2021	01	Optimum Diamond Rewards (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	031	0	2021	01	Optimum Diamond Rewards COPD (HMO C-SNP)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	032	0	2021	01	Optimum Gold Plus Plan (HMO)	Select Counties in Florida		Select Counties in Florida	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	034	0	2021	01	Optimum Diamond Rewards (HMO C-SNP)	select counties in FL		select counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5594	035	0	2021	01	Optimum Diamond Rewards COPD (HMO C-SNP)	select counties in FL		select counties in FL	1	0	0	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	5403 N. Church Ave.		Tampa	FL	33614		member_services@youroptimumhealthcare.com	member_services@youroptimumhealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourOptimumHealthcare.com	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com	www.youroptimumhealthcare.com
H5599	001	0	2021	01	Fidelis Dual Advantage Flex (HMO D-SNP)	NY Counties	Fidelis Dual Advantage Flex (HMO D-SNP)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	fideliscare.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	002	0	2021	02	Fidelis Medicare Advantage Flex (HMO-POS)	NY Counties	Fidelis Medicare Advantage Flex (HMO-POS)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	fideliscare.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	003	0	2021	01	Fidelis Medicaid Advantage Plus (HMO D-SNP)	NY Counties	Fidelis Medicaid Advantage Plus (HMO D-SNP)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	fideliscare.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	004	0	2021	01	Fidelis Medicare $0 Premium (HMO)	NY Counties	Fidelis Medicare Prima $0 (HMO)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fideliscare.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	005	0	2021	02	Fidelis Medicare Advantage without Rx (HMO-POS)	NY Counties	Fidelis Medicare Advantage without Rx (HMO-POS)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	fideliscare.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	006	0	2021	01	Fidelis Dual Advantage (HMO D-SNP)	NY Counties	Fidelis Dual Advantage (HMO D-SNP)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	fideliscare.org	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	007	0	2021	02	Fidelis Medicare Advantage Flex (HMO-POS)	NY Counties	Fidelis Medicare Advantage Flex (HMO-POS)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	fideliscare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	008	0	2021	01	Fidelis Medicaid Advantage Plus (HMO D-SNP)	NY Counties	Fidelis Medicaid Advantage Plus (HMO D-SNP)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	fideliscare.org	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	009	0	2021	01	Fidelis Medicare $0 Premium (HMO)	NY Counties	Fidelis Medicare Prima $0 (HMO)	NY Counties	1	0	0	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fideliscare.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	801	0	2021	02	Fidelis Medicare Advantage Employer without RX (HMO-POS)	New York Counties		New York Counties	1	3	1	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	fideliscare.org/	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	802	0	2021	02	Fidelis Medicare Advantage Employer (HMO-POS)	New York Counties		New York Counties	1	3	1	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	fideliscare.org/	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5599	803	0	2021	02	Fidelis Medicare Advantage Employer (HMO-POS)	New York Counties		New York Counties	1	3	1	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	95-25 Queens Boulevard		Rego Park	NY	11374		memberservices@fideliscare.org	memberservices@fideliscare.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	fideliscare.org/	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	fideliscare.org/Find-A-Doctor	fideliscare.org/Find-A-Doctor	fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
H5608	001	0	2021	01	Denver Health Medicare Choice (HMO D-SNP)	Denver, Jefferson and Adams Counties		Denver, Jefferson and Adams Counties	1	0	0	777 Bannock Street	mail code 6000	Denver	CO	80204				777 Bannock Street	mail code 6000	Denver	CO	80204				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.denverhealthmedicalplan.org	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.denverhealthmedicalplan.org	www.denverhealthmedicalplan.org	www.denverhealthmedicalplan.org
H5608	002	0	2021	01	Denver Health Medicare Select (HMO)	Adams, Denver, and Jefferson counties		Adams, Denver, and Jefferson counties	1	0	0	777 Bannock Street	mail code 6000	Denver	CO	80204				777 Bannock Street	mail code 6000	Denver	CO	80204				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.denverhealthmedicalplan.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.denverhealthmedicalplan.org	www.denverhealthmedicalplan.org	www.denverhealthmedicalplan.org
H5608	802	0	2021	01	Denver Health Medical Plan Medicare Advantage (HMO)	Adams, Denver, and Jefferson Counties		Adams, Denver, and Jefferson Counties	1	3	1	777 Bannock Street	mail code 6000	Denver	CO	80204				777 Bannock Street	mail code 6000	Denver	CO	80204				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.denverhealthmedicalplan.org	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.denverhealthmedicalplan.org	www.denverhealthmedicalplan.org	www.denverhealthmedicalplan.org
H5610	001	0	2021	20	Care Resources (PACE)	Kent County		Kent County	1	3	0									4150 Kalamazoo Avenue SE		Grand Rapids	MI	49508			info@care-resources.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.careresources.org	0	0	1			0					3	0	0		www.careresources.org	www.careresources.org
H5610	003	0	2021	20	Care Resources (PACE)	Kent County		Kent County	1	3	0									4150 Kalamazoo Avenue SE		Grand Rapids	MI	49508			info@care-resources.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.careresources.org	0	0	1			0					3	0	0		www.careresources.org	www.careresources.org
H5613	002	0	2021	07	MVP SmartFund (MSA)	Eastern NY		Eastern NY	1	3	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	mvphealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H5613	801	0	2021	07	MVP SmartFund EG (MSA)	Western NY		Western NY	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	mvphealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H5613	802	0	2021	07	MVP SmartFund EG (MSA)	Eastern NY		Eastern NY	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	mvphealthcare.com	0	0	2			0	<ul><li>Additional restrictions apply to enrollment in an MSA plan. Please contact this plan to enroll. Once you reach the plan deductible, Medicare MSA plans cover Original Medicare benefits.  Co-pay for Medicare MSAs is $0 once deductible is met.</li><li>Please note, preventive services are also subject to satisfying your MSA plan deductible, so once you've met your deductible you'll then pay nothing</li></ul>	<ul><li>Restricciones adicionales aplican en un plan de MSA. Favor de comunicarse con el plan para inscribirse. Una vez que alcance el deducible del plan, los planes MSA cubrirán los beneficios de Medicare. Los copagos de los MSA serán $0, después que se cumple con el deducible.</li><li>Tenga en cuenta que los servicios preventivos también satisfacen el deducible de su plan MSA, así que una vez cumpla con su deducible, no tendrá que pagar.</li></ul>			3	0	0			
H5619	001	0	2021	01	Humana Gold Plus H5619-001 (HMO)	Southern Maine		Southern Maine	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	003	0	2021	01	Humana Gold Plus SNP-DE H5619-003 (HMO D-SNP)	Maine		Maine	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	012	0	2021	01	Humana Gold Plus H5619-012 (HMO)	Fresno County		Fresno County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	013	0	2021	01	Humana Gold Plus H5619-013 (HMO)	Madera County		Madera County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	015	0	2021	01	Humana Gold Plus H5619-015 (HMO)	Tulare and Kings counties		Tulare and Kings counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	016	0	2021	01	Humana Gold Plus H5619-016 (HMO)	San Diego County		San Diego County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	021	0	2021	01	Humana Gold Plus H5619-021 (HMO)	Los Angeles and Orange counties		Los Angeles and Orange counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	026	0	2021	01	Humana Gold Plus H5619-026 (HMO)	San Joaquin County		San Joaquin County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	029	0	2021	01	Humana Gold Plus H5619-029 (HMO)	Contra Costa County		Contra Costa County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	032	0	2021	01	Humana Gold Plus H5619-032 (HMO)	Stanislaus County		Stanislaus County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	037	0	2021	01	Humana Value Plus H5619-037 (HMO)	Select Counties in California		Select Counties in California	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	038	0	2021	01	Humana Gold Plus SNP-DE H5619-038 (HMO D-SNP)	Select Counties in California		Select Counties in California	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	039	1	2021	01	Humana Gold Plus H5619-039 (HMO)	Riverside and San Bernardino counties		Riverside and San Bernardino counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	039	2	2021	01	Humana Gold Plus H5619-039 (HMO)	Riverside and San Bernardino counties		Riverside and San Bernardino counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	041	0	2021	01	Humana Gold Plus H5619-041 (HMO)	Albemarle and Charlottesville City Counties		Albemarle and Charlottesville City Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $215.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $215.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	044	0	2021	01	Humana Gold Plus H5619-044 (HMO)	Richmond Metro Area		Richmond Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	045	0	2021	01	Humana Gold Plus H5619-045 (HMO)	Tidewater Area		Tidewater Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	046	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Richmond - Tidewater Area		Richmond - Tidewater Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	047	0	2021	01	Humana Gold Plus H5619-047 (HMO)	Northern Virginia Area		Northern Virginia Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	049	0	2021	01	Humana Gold Plus H5619-049 (HMO)	Indianapolis Metro Area		Indianapolis Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	050	0	2021	01	Humana Gold Plus H5619-050 (HMO)	Evansville Metro Area		Evansville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	051	0	2021	01	Humana Gold Plus H5619-051 (HMO)	Fort Wayne Metro Area		Fort Wayne Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	052	0	2021	01	Humana Gold Plus H5619-052 (HMO)	South Bend Metro Area		South Bend Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	053	0	2021	01	Humana Gold Plus H5619-053 (HMO)	Lake and Porter County		Lake and Porter County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	054	0	2021	01	Humana Gold Plus SNP-DE H5619-054 (HMO D-SNP)	Select counties in Indiana		Select counties in Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	055	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Select counties in Kentucky and Indiana		Select counties in Kentucky and Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	056	0	2021	01	Humana Gold Plus H5619-056 (HMO)	Clark and Cowlitz Counties		Clark and Cowlitz Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	057	0	2021	01	Humana Gold Plus H5619-057 (HMO)	King County		King County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	059	0	2021	01	Humana Gold Plus H5619-059 (HMO)	Snohomish County		Snohomish County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	060	0	2021	01	Humana Gold Plus H5619-060 (HMO)	Spokane County		Spokane County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	061	0	2021	01	Humana Gold Plus H5619-061 (HMO)	Pierce County		Pierce County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	062	0	2021	01	Humana Gold Plus H5619-062 (HMO)	Thurston County		Thurston County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	063	0	2021	01	Humana Gold Plus H5619-063 (HMO)	Snohomish County		Snohomish County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	064	0	2021	01	Humana Gold Plus H5619-064 (HMO)	Thurston County		Thurston County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	065	0	2021	01	Humana Value Plus H5619-065 (HMO)	New Hampshire		New Hampshire	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	066	0	2021	01	Humana Gold Plus H5619-066 (HMO)	Maine		Maine	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	069	0	2021	01	Humana Gold Plus H5619-069 (HMO)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	071	0	2021	01	Humana Gold Plus H5619-071 (HMO)	Lexington Metro Area		Lexington Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	073	0	2021	01	Humana Gold Plus H5619-073 (HMO)	Louisville Metro Area		Louisville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	075	0	2021	01	Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP)	Central Kentucky Area		Central Kentucky Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	076	0	2021	01	Humana Gold Plus SNP-DE H5619-076 (HMO D-SNP)	Clark, Floyd and Harrison counties		Clark, Floyd and Harrison counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	077	0	2021	01	Humana Gold Plus H5619-077 (HMO)	Ada, Canyon and Payette counties		Ada, Canyon and Payette counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	078	0	2021	01	Humana Gold Plus H5619-078 (HMO)	Bonner and Kootenai counties		Bonner and Kootenai counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	080	0	2021	01	Humana Gold Plus H5619-080 (HMO)	Richland County		Richland County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	082	0	2021	01	Humana Gold Plus SNP-DE H5619-082 (HMO D-SNP)	South Carolina		South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	083	0	2021	01	Humana Gold Plus H5619-083 (HMO)	Charleston Metro Area		Charleston Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	086	0	2021	01	Humana Gold Plus H5619-086 (HMO)	Spartanburg/Greenville Metro Area		Spartanburg/Greenville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	087	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Upstate South Carolina		Upstate South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	088	0	2021	01	Humana Gold Plus H5619-088 (HMO)	Birmingham Metro Area		Birmingham Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	089	0	2021	01	Humana Gold Plus H5619-089 (HMO)	Mobile Metro Area		Mobile Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	090	0	2021	02	Humana Gold Plus H5619-090 (HMO-POS)	Select VA Counties in the Tri-Cities Area		Select VA Counties in the Tri-Cities Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	091	0	2021	02	Humana Gold Plus H5619-091 (HMO-POS)	Select VA Counties in the Tri-Cities Area		Select VA Counties in the Tri-Cities Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	093	0	2021	01	Humana Gold Plus SNP-DE H5619-093 (HMO D-SNP)	Greater Alabama		Greater Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	094	0	2021	01	Humana Gold Plus H5619-094 (HMO)	Huntsville Metro Area		Huntsville Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	095	0	2021	02	Humana Gold Plus H5619-095 (HMO-POS)	Select VA Counties in the Tri-Cities Area		Select VA Counties in the Tri-Cities Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	097	0	2021	01	Humana Gold Plus H5619-097 (HMO)	King County		King County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	099	0	2021	01	Humana Gold Plus H5619-099 (HMO)	Kitsap County		Kitsap County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	100	0	2021	01	Humana Gold Plus H5619-100 (HMO)	Pierce County		Pierce County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	101	0	2021	01	Humana Gold Plus H5619-101 (HMO)	Clark and Cowlitz counties		Clark and Cowlitz counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	109	0	2021	01	Humana Value Plus H5619-109 (HMO)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	111	0	2021	01	Humana Gold Plus H5619-111 (HMO)	Northwest Arkansas		Northwest Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	112	0	2021	01	Humana Gold Plus H5619-112 (HMO)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	113	0	2021	01	Humana Gold Plus H5619-113 (HMO)	Select Counties in West Virginia and Kentucky		Select Counties in West Virginia and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	114	0	2021	01	Humana Gold Plus H5619-114 (HMO)	Whatcom and Skagit Counties		Whatcom and Skagit Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	115	0	2021	01	Humana Gold Plus H5619-115 (HMO)	Whatcom and Skagit Counties		Whatcom and Skagit Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	116	0	2021	01	Humana Gold Plus H5619-116 (HMO)	Kern County		Kern County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	118	0	2021	01	Humana Gold Plus H5619-118 (HMO)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	119	0	2021	01	Humana Gold Plus H5619-119 (HMO)	San Luis Obispo County		San Luis Obispo County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	120	0	2021	01	Humana Honor (HMO)	Los Angeles, Orange and San Diego counties		Los Angeles, Orange and San Diego counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	121	0	2021	01	Humana Honor (HMO)	Kern, Riverside, San Bernardino, Ventura counties		Kern, Riverside, San Bernardino, Ventura counties	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	122	0	2021	01	Humana Gold Plus H5619-122 (HMO)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	123	0	2021	01	Humana Gold Plus SNP-DE H5619-123 (HMO D-SNP)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	124	0	2021	01	Humana Gold Plus H5619-124 (HMO)	Indianapolis Metro Area		Indianapolis Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	126	0	2021	01	Humana Gold Plus SNP-DE H5619-126 (HMO D-SNP)	Select Counties in West Virginia		Select Counties in West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	128	0	2021	01	Humana Gold Plus H5619-128 (HMO)	Bowling Green Kentucky		Bowling Green Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	129	0	2021	01	Humana Gold Plus H5619-129 (HMO)	Island County		Island County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	130	1	2021	01	Humana Gold Plus H5619-130 (HMO)	Santa Barbara (partial) and Ventura counties		Santa Barbara (partial) County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	130	2	2021	01	Humana Gold Plus H5619-130 (HMO)	Santa Barbara (partial) and Ventura counties		Ventura County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	131	0	2021	01	UC San Diego Health Humana (HMO)	San Diego County		San Diego County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	132	1	2021	01	Humana Gold Plus H5619-132 (HMO)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	132	2	2021	01	Humana Gold Plus H5619-132 (HMO)	Select Counties in South Carolina		Charleston Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	133	0	2021	01	Humana Gold Plus H5619-133 (HMO)	Benton, Franklin and Walla Walla counties		Benton, Franklin and Walla Walla counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	134	0	2021	01	Humana Value Plus H5619-134 (HMO)	Select counties in Washington		Select counties in Washington	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	135	0	2021	01	Humana Gold Plus H5619-135 (HMO)	Roanoke Metro Area		Roanoke Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	136	1	2021	01	Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)	Select counties in Washington		Clark County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	136	2	2021	01	Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)	Select counties in Washington		Snohomish County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	136	3	2021	01	Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)	Select counties in Washington		Skagit and Whatcom counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	136	4	2021	01	Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)	Select counties in Washington		Select counties in Washington	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	137	0	2021	01	Humana Gold Plus H5619-137 (HMO)	Select Counties in Maine and New Hampshire		Select Counties in Maine and New Hampshire	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	802	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	803	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	805	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5619	806	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Multi States		Select Counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5628	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Utah		Select Counties in Utah	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5628	007	0	2021	01	Molina Medicare Choice Care (HMO)	Wasatch Front and Cache, Tooele, Summit Counties		Wasatch Front and Cache, Tooele, Summit Counties	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5628	008	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Idaho		Select Counties in Idaho	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5628	009	0	2021	01	Molina Medicare Choice Care (HMO)	Ada and Canyon Counties		Ada and Canyon Counties	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5628	010	0	2021	01	Molina Medicare Choice Care (HMO)	Twin Falls County		Twin Falls County	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5629	001	0	2021	20	St. Paul's PACE (PACE)	San Diego County	St. Paul's PACE (PACE)	San Diego County	1	3	0									111 Elm Street		San Diego	CA	92101		PACEenrollments@stpaulspace.org	PACEenrollments@stpaulspace.org	5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.stpaulspace.org/	0	0	1			0					3	0	0		stpaulspace.org	stpaulspace.org
H5629	002	0	2021	20	St. Paul's PACE (PACE)	San Diego County, South County	St. Paul's PACE (PACE)	San Diego County, South County	1	3	0									630 L Street		Chula Vista	CA	91911		PACEenrollments@stpaulspace.org	PACEenrollments@stpaulspace.org	5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.stpaulspace.org/	0	0	1			0					3	0	0		stpaulspace.org	stpaulspace.org
H5644	002	0	2021	01	Network Health Medicare Explore (HMO)	Southeast Wisconsin		Southeast Wisconsin	1	0	0	1570 Midway Place	P.O. Box 120	Menasha	WI	54952				1570 Midway Place	P.O. Box 120	Menasha	WI	54952				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://networkhealth.com/	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://networkhealth.com/find-a-doctor/	https://networkhealth.com/find-a-pharmacy.html	https://networkhealth.com/look-up-medications.html
H5649	001	0	2021	01	Central Health Medicare Plan (HMO)	Counties:  LA, SB, RS, OC	Central Health Medicare Plan (HMO)	Counties:  LA, SB, RS, OC	1	0	0	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centralhealthplan.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.centralhealthplan.com/NetworkProviders/Directory.aspx	www.centralhealthplan.com/Benefits/PharmacyList.aspx	www.centralhealthplan.com/PartD/Formulary
H5649	002	0	2021	01	Central Health Medi-Medi Plan (HMO D-SNP)	Counties: LA and SB	Central Health Medi-Medi Plan (HMO D-SNP)	Counties: LA and SB	1	0	0	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centralhealthplan.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.centralhealthplan.com/NetworkProviders/Directory.aspx	www.centralhealthplan.com/Benefits/PharmacyList.aspx	www.centralhealthplan.com/PartD/Formulary
H5649	004	0	2021	01	Central Health Premier Plan (HMO)	Counties:  LA, SB, RS, OC	Central Health Premier Plan (HMO)	Counties:  LA, SB, RS, OC	1	0	0	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centralhealthplan.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.centralhealthplan.com/NetworkProviders/Directory.aspx	www.centralhealthplan.com/Benefits/PharmacyList.aspx	www.centralhealthplan.com/PartD/Formulary
H5649	006	0	2021	01	Central Health Focus Plan (HMO C-SNP)	Counties:  LA, SB, OC	Central Health Focus Plan (HMO C-SNP)	Counties:  LA, SB, OC	1	0	0	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centralhealthplan.com	1	4	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.centralhealthplan.com/NetworkProviders/Directory.aspx	www.centralhealthplan.com/Benefits/PharmacyList.aspx	www.centralhealthplan.com/PartD/Formulary
H5649	008	0	2021	01	Central Health Ventura Medicare Plan (HMO)	Ventura County	Central Health Ventura Medicare Plan (HMO)	Ventura County	1	0	0	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centralhealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.centralhealthplan.com/NetworkProviders/Directory.aspx	www.centralhealthplan.com/Benefits/PharmacyList.aspx	www.centralhealthplan.com/PartD/Formulary
H5649	009	0	2021	01	Central Health Ventura Medi-Medi Plan (HMO D-SNP)	Ventura County	Central Health Ventura Medi-Medi Plan (HMO D-SNP)	Ventura County	1	0	0	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	1540 Bridgegate Drive		Diamond Bar	CA	91765		memberservices@centralhealthplan.com	memberservices@centralhealthplan.com	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centralhealthplan.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.centralhealthplan.com/NetworkProviders/Directory.aspx	www.centralhealthplan.com/Benefits/Pharmacy.aspx	www.centralhealthplan.com/PartD/Formulary
H5652	001	0	2021	02	Erickson Advantage Signature with Drugs (HMO-POS)	Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC		Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.EricksonAdvantage.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.EricksonAdvantage.com	www.EricksonAdvantage.com	www.EricksonAdvantage.com
H5652	002	0	2021	02	Erickson Advantage Liberty without Drugs (HMO-POS)	Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC		Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.EricksonAdvantage.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.EricksonAdvantage.com	www.EricksonAdvantage.com	www.EricksonAdvantage.com
H5652	003	0	2021	02	Erickson Advantage Guardian (HMO-POS I-SNP)	Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC		Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.EricksonAdvantage.com	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.EricksonAdvantage.com	www.EricksonAdvantage.com	www.EricksonAdvantage.com
H5652	004	0	2021	02	Erickson Advantage Champion (HMO-POS C-SNP)	Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC		Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.EricksonAdvantage.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.EricksonAdvantage.com	www.EricksonAdvantage.com	www.EricksonAdvantage.com
H5652	006	0	2021	02	Erickson Advantage Freedom (HMO-POS)	Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC		Erickson Campuses - CO,KS,MA,MD,MI,NJ,PA,TX,VA,NC	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.EricksonAdvantage.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.EricksonAdvantage.com	www.EricksonAdvantage.com	www.EricksonAdvantage.com
H5652	008	0	2021	02	Erickson Advantage Liberty with Drugs (HMO-POS)	CO/KS/MD/MA/MI/NJ/NC/PA/TX/VA		CO/KS/MD/MA/MI/NJ/NC/PA/TX/VA	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.EricksonAdvantage.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.EricksonAdvantage.com	www.EricksonAdvantage.com	www.EricksonAdvantage.com
H5656	001	0	2021	01	WellCare TexanPlus Classic (HMO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5656	801	0	2021	01	Retiree - MA-PD CY (HMO)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5656	802	0	2021	01	Retiree - MA-PD non-CY (HMO)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5656	803	0	2021	01	Retiree - MA (HMO)	Select counties in TX		Select counties in TX	1	3	1	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5703	001	0	2021	01	AbilityCare (HMO D-SNP)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	South Country Health Alliance	2300 Park Drive, Suite 100	Owatonna	MN	55060		members@mnscha.org	members@mnscha.org	South Country Health Alliance	2300 Park Drive, Suite 100	Owatonna	MN	55060		members@mnscha.org	members@mnscha.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.mnscha.org	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.mnscha.org	www.mnscha.org	www.mnscha.org
H5742	001	0	2021	01	FirstCare Advantage Dual SNP Premier (HMO D-SNP)	West Texas		West Texas	1	0	0	7005 Salem Park Drive	Suite 100	Lubbock	TX	79424		cservice@firstcare.com	cservice@firstcare.com	7005 Salem Park Drive	Suite 100	Lubbock	TX	79424		cservice@firstcare.com	cservice@firstcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.firstcare.com/dualsnp	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.firstcare.com/dualsnp	www.firstcare.com/dualsnp	www.firstcare.com/dualsnp
H5742	002	0	2021	01	FirstCare Advantage Dual SNP Select (HMO D-SNP)	West Texas		West Texas	1	0	0	7005 Salem Park Drive	Suite 100	Lubbock	TX	79424		cservice@firstcare.com	cservice@firstcare.com	7005 Salem Park Drive	Suite 100	Lubbock	TX	79424		cservice@firstcare.com	cservice@firstcare.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.firstcare.com/dualsnp	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.firstcare.com/dualsnp	www.firstcare.com/dualsnp	www.firstcare.com/dualsnp
H5746	016	0	2021	01	Amerivantage Care Access (HMO)	Greater Albuquerque Area		Greater Albuquerque Area	1	0	0	Amerigroup New Mexico	6565 Americas Parkway, NE, Suite 110	Albuquerque	NM	87110		seniornewenroll@bluecrossca.com		Amerigroup New Mexico	6565 Americas Parkway, NE, Suite 110	Albuquerque	NM	87710		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H5746	018	0	2021	01	Amerivantage Plus (HMO)	Greater Albuquerque area		Greater Albuquerque area	1	0	0	Amerigroup New Mexico	6565 Americas Parkway, NE, Suite 110	Albuquerque	NM	87110		seniornewenroll@bluecrossca.com		Amerigroup New Mexico	6565 Americas Parkway, NE, Suite 110	Albuquerque	NM	87710		seniornewenroll@bluecrossca.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare/	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare/	www.myamerigroup.com/medicare	www.myamerigroup.com/medicare
H5774	003	0	2021	01	Basic (HMO)	Puerto Rico	Basic (HMO)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com									1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	005	0	2021	01	Real (HMO)	Puerto Rico	Real (HMO)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	022	0	2021	01	Contigo Plus (HMO C-SNP)	Puerto Rico	Contigo Plus (HMO C-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	4	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	024	0	2021	01	Platino Plus (HMO D-SNP)	Puerto Rico	Platino Plus (HMO D-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	025	0	2021	01	Platino Ultra (HMO D-SNP)	Puerto Rico	Platino Ultra (HMO D-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	026	0	2021	01	Platino Advance (HMO D-SNP)	Puerto Rico	Platino Advance (HMO D-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	027	0	2021	02	Magno (HMO-POS)	Puerto Rico	Magno (HMO-POS)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	028	0	2021	01	Platino Blindao (HMO D-SNP)	Puerto Rico	Platino Blindao (HMO D-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	031	0	2021	02	Brillante (HMO-POS)	Puerto Rico	Brillante (HMO-POS)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	032	0	2021	01	Platino Enlace (HMO D-SNP)	Puerto Rico	Platino Enlace (HMO D-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	033	0	2021	01	Enlace (HMO)	Puerto Rico	Enlace (HMO)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	035	0	2021	01	Platino Alcance (HMO D-SNP)	Puerto Rico	Platino Alcance (HMO D-SNP)	Puerto Rico	1	0	0	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	802	0	2021	01	Royal A (HMO)	Puerto Rico	Royal A (HMO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com									1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	2	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	806	0	2021	01	Royal B (HMO)	Puerto Rico	Royal B (HMO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	808	0	2021	01	Royal C (HMO)	Puerto Rico	Royal C (HMO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	809	0	2021	02	Royal D (HMO-POS)	Puerto Rico	Royal D (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	810	0	2021	01	Royal E (HMO)	Puerto Rico	Royal E (HMO)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	811	0	2021	02	Royal Plus A (HMO-POS)	Puerto Rico	Royal Plus A (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	812	0	2021	02	Employer BD 1 (HMO-POS)	Puerto Rico	Employer BD 1 (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	814	0	2021	02	Employer BD 3 (HMO-POS)	Puerto Rico	Employer BD 3 (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	816	0	2021	02	Employer BD 5 (HMO-POS)	Puerto Rico	Employer BD 5 (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	818	0	2021	02	Employer BD 7 (HMO-POS)	Puerto Rico	Employer BD 7 (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5774	820	0	2021	02	Employer BD 8 (HMO-POS)	Puerto Rico	Employer BD 8 (HMO-POS)	Puerto Rico	1	3	1	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	PO Box 11320		San Juan	PR	00922		lgil@sssadvantage.com	grmartinez@ssspr.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.sssadvantage.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.sssadvantage.com	www.sssadvantage.com	www.sssadvantage.com
H5779	002	0	2021	01	WellCare Essential (HMO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5779	005	0	2021	01	WellCare Essential (HMO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5779	006	0	2021	01	WellCare Edge (HMO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5779	007	0	2021	01	WellCare Exclusive (HMO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5793	001	0	2021	01	Aetna Medicare Value Plan (HMO)	Connecticut		Connecticut	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	010	0	2021	01	Aetna Medicare Elite Plan (HMO)	Connecticut		Connecticut	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	012	0	2021	01	Aetna Medicare Prime PCP Elite Plan (HMO)	Connecticut		Connecticut	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	014	0	2021	01	Aetna Medicare Value Plan (HMO)	Central Massachusetts		Central Massachusetts	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	015	0	2021	01	Aetna Medicare Elite Plan (HMO)	New Hampshire		New Hampshire	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	016	0	2021	01	Aetna Medicare Value Plan (HMO)	Rhode Island		Rhode Island	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	017	0	2021	02	Aetna Medicare Assure Plan (HMO-POS D-SNP)	Connecticut		Connecticut	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	018	0	2021	01	Aetna Medicare Value Plan (HMO)	Eastern Massachusetts		Eastern Massachusetts	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	801	0	2021	01	Aetna Medicare Plan (HMO)	Connecticut		Connecticut	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5793	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Connecticut		Connecticut	1	3	1	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	151 Farmington Avenue		Hartford	CT	06156			HicksJS@aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H5810	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Counties: LA, SD, parts of Riv. and S. Bernardino		Counties: LA, SD, parts of Riv. and S. Bernardino	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5810	013	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Imperial County		Imperial County	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5822	001	0	2021	20	Midland Care Connection - Dual Eligibles (PACE)	DG,JA,JF,LY,LV,MS,NM,OS,PT,SN,WB,WY counties		DG,JA,JF,LY,LV,MS,NM,OS,PT,SN,WB,WY counties	1	3	0									200 SW Frazier Circle		Topeka	KS	66606				3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.midlandcareconnection.org	0	0	1			0					3	0	0		N/A	N/A
H5822	002	0	2021	20	Midland Care Connection - Medicare Only (PACE)	DG,JA,JF,LY,LV,MS,NM,OS,PT,SN,WB,WYcounties		DG,JA,JF,LY,LV,MS,NM,OS,PT,SN,WB,WYcounties	1	3	0									200 SW Frazier Circle		Topeka	KS	66606				3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.midlandcc.org	0	0	1			0					3	0	0		N/A	N/A
H5823	006	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Washington		Select Counties in Washington	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5826	006	0	2021	01	Community Health Plan of WA MA No Rx Plan (HMO)	Western Washington and Spokane Counties		Western Washington and Spokane Counties	1	0	0	1111 3rd Avenue	Suite 400	Seattle	WA	98101												5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.medicare.chpw.org	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.medicare.chpw.org	www.medicare.chpw.org	www.medicare.chpw.org
H5826	008	0	2021	01	Community Health Plan of WA MA Plan 3 (HMO)	Western Washington and Spokane Counties		Western Washington and Spokane Counties	1	0	0	1111 3rd Avenue	Suite 400	Seattle	WA	98101				1111 3rd Avenue	Suite 400	Seattle	WA	98101				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.medicare.chpw.org	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.medicare.chpw.org	www.medicare.chpw.org	www.medicare.chpw.org
H5826	009	0	2021	01	Community Health Plan of WA MA Plan 4 (HMO)	Eastern and Western Washington State		Eastern and Western Washington State	1	0	0	1111 3rd Avenue	Suite 400	Seattle	WA	98101				1111 3rd Avenue	Suite 400	Seattle	WA	98101				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.medicare.chpw.org	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.medicare.chpw.org	www.medicare.chpw.org	www.medicare.chpw.org
H5826	010	0	2021	01	Community Health Plan of WA MA Plan 2 (HMO)	Eastern and Western Washington State		Eastern and Western Washington State	1	0	0	1111 3rd Avenue	Suite 400	Seattle	WA	98101				1111 3rd Avenue	Suite 400	Seattle	WA	98101				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.medicare.chpw.org	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.medicare.chpw.org	www.medicare.chpw.org	www.medicare.chpw.org
H5826	014	0	2021	01	Community Health Plan of WA Dual Plan (HMO D-SNP)	Eastern and Western Washington State		Eastern and Western Washington State	1	0	0	1111 3rd Avenue	Suite 400	Seattle	WA	98101				1111 3rd Avenue	Suite 400	Seattle	WA	98101				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.medicare.chpw.org	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.medicare.chpw.org	www.medicare.chpw.org	www.medicare.chpw.org
H5826	016	0	2021	01	Community Health Plan of WA MA Plan 1 (HMO)	Eastern and Western Washington State		Eastern and Western Washington State	1	0	0	1111 3rd Avenue	Suite 400	Seattle	WA	98101				1111 3rd Avenue	Suite 400	Seattle	WA	98101				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.medicare.chpw.org	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $230.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $230.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.medicare.chpw.org	www.medicare.chpw.org	www.medicare.chpw.org
H5828	001	0	2021	01	Amerivantage Full Dual Coordination (HMO D-SNP)	Tennessee		Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H5828	002	0	2021	01	Amerivantage Dual Premier (HMO D-SNP)	Tennessee		Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H5828	005	0	2021	02	Amerivantage Classic Plus (HMO-POS)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H5828	006	0	2021	02	Amerivantage Classic Plus (HMO-POS)	Select Counties in Tennessee		Select Counties in Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H5828	007	0	2021	01	Amerivantage Select Plus (HMO)	Shelby County		Shelby County	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H5828	008	0	2021	01	Amerivantage Balance Plus (HMO)	Tennessee		Tennessee	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H5841	001	0	2021	04	Bright Advantage Choice (PPO)	Greater Denver Area		Greater Denver Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H5841	002	0	2021	04	Bright Advantage Choice Plus (PPO)	Greater Denver Area		Greater Denver Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H5841	003	0	2021	04	Bright Advantage Choice (PPO)	Phoenix Area		Phoenix Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H5841	004	0	2021	04	Bright Advantage Choice Plus (PPO)	Phoenix Area		Phoenix Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H5841	005	0	2021	04	Bright Advantage Choice (PPO)	Omaha Area		Omaha Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H5841	010	0	2021	04	Bright Advantage Choice Plus (PPO)	Omaha Area		Omaha Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H5843	001	0	2021	01	Banner Medicare Advantage Prime (HMO)	Maricopa and Pinal Counties	Banner Medicare Advantage Prime (HMO)	Maricopa and Pinal Counties	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BannerMA.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.BannerMA.com	https://www.bannerhealth.com/	https://www.bannerhealth.com/
H5843	002	0	2021	01	Banner Medicare Advantage Prime (HMO)	Pima County	Banner Medicare Advantage Prime (HMO)	Pima County	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BannerMA.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.BannerMA.com	https://www.bannerhealth.com/	https://www.bannerhealth.com/
H5852	001	0	2021	01	PHP (HMO C-SNP)	Los Angeles County, California	PHP (HMO C-SNP)	Los Angeles County, California	1	0	0	P.O. Box 46160		Los Angeles	CA	90046		php@positivehealthcare.org	php@positivehealthcare.org	P.O. Box 46160		Los Angeles	CA	90046		php@positivehealthcare.org	php@positivehealthcare.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.php-ca.org	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.php-ca.org/provider-find	www.php-ca.org/provider-find	www.php-ca.org/for-members/drug-benefit/formulary
H5854	007	0	2021	01	Anthem MediBlue Plus (HMO)	Hartford County		Hartford County	1	0	0	P.O. Box 659403		San Antonio	TX	78265				P.O. Box 659403		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	008	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265				P.O. Box 659403		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	009	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Connecticut		Select Counties in Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265				P.O. Box 659403		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	010	0	2021	01	Anthem MediBlue Select (HMO)	Select Counties in Connecticut		Select Counties in Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659403		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	011	0	2021	01	Anthem MediBlue Extra (HMO)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659403		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	012	0	2021	02	Anthem MediBlue ESRD Care (HMO-POS C-SNP)	Select Counties in Connecticut		Select Counties in Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659403		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.anthem.com/shop	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	013	0	2021	01	Anthem MediBlue Dual Advantage Select (HMO D-SNP)	State of Connecticut		State of Connecticut	1	0	0	P.O. Box 659403		San Antonio	TX	78265				P.O. Box 659403		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	014	0	2021	01	Anthem MediBlue Care To You (HMO I-SNP)	Select Counties in CT		Select Counties in CT	1	0	0	12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				12900 Park Plaza Drive, Suite 150		Cerritos	CA	90703				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	1	1	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	015	0	2021	01	Anthem MediBlue Prime (HMO)	New Haven		New Haven	1	0	0	P.O. Box 659403		San Antonio	TX	78265				P.O. Box 659403		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H5854	801	0	2021	01	Anthem MediBlue (HMO)	Connecticut - Select Counties		Connecticut - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	803	0	2021	01	Anthem MediBlue (HMO)	Connecticut - Select Counties		Connecticut - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	806	0	2021	01	Anthem MediBlue (HMO)	Conneticut - Select Counties		Conneticut - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	807	0	2021	01	Anthem MediBlue (HMO)	Select Conneticut Counties		Select Conneticut Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	808	0	2021	01	Anthem MediBlue (HMO)	Select Conneticut Counties		Select Conneticut Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	809	0	2021	01	Anthem MediBlue (HMO)	Select Conneticut Counties		Select Conneticut Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	810	0	2021	01	Anthem MediBlue (HMO)	Select Conneticut Counties		Select Conneticut Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5854	811	0	2021	01	Anthem MediBlue (HMO)	Select CT counties		Select CT counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ct/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare	www.anthem.com/ct/medicare
H5859	001	0	2021	02	CareOregon Advantage Plus (HMO-POS D-SNP)	Portland Metro Area, Jackson, Tillamook, Columbia		Portland Metro Area, Jackson, Tillamook, Columbia	1	0	0	CareOregon Advantage	315 SW Fifth Avenue	Portland	OR	97204				CareOregon Advantage	315 SW Fifth Avenue	Portland	OR	97204				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.careoregonadvantage.org	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	http://www.careoregonadvantage.org/member-resources/find-a-provider	http://www.careoregonadvantage.org/member-resources/find-a-provider	http://www.careoregonadvantage.org/member-resources/rx-and-drug-information/are-my-drugs-covered-
H5883	001	1	2021	02	BCN Advantage HMO-POS Elements (HMO-POS)	Michigan		Region 1	1	0	0	20500 Civic Center Drive		Southfield	MI	48076												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	001	2	2021	02	BCN Advantage HMO-POS Elements (HMO-POS)	Michigan		Region 2	1	0	0	20500 Civic Center Drive		Southfield	MI	48076												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	001	3	2021	02	BCN Advantage HMO-POS Elements (HMO-POS)	Michigan		Region 3	1	0	0	20500 Civic Center Drive		Southfield	MI	48076												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	001	4	2021	02	BCN Advantage HMO-POS Elements (HMO-POS)	Michigan		Region 4	1	0	0	20500 Civic Center Drive		Southfield	MI	48076												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	001	5	2021	02	BCN Advantage HMO-POS Elements (HMO-POS)	Michigan		Region 5	1	0	0	20500 Civic Center Drive		Southfield	MI	48076												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	002	1	2021	02	BCN Advantage HMO-POS Classic (HMO-POS)	Michigan		Region 1	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	002	2	2021	02	BCN Advantage HMO-POS Classic (HMO-POS)	Michigan		Region 2	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	002	3	2021	02	BCN Advantage HMO-POS Classic (HMO-POS)	Michigan		Region 3	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	002	4	2021	02	BCN Advantage HMO-POS Classic (HMO-POS)	Michigan		Region 4	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	002	7	2021	02	BCN Advantage HMO-POS Classic (HMO-POS)	Michigan		Region 5	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	003	1	2021	02	BCN Advantage HMO-POS Prestige (HMO-POS)	Michigan		Region 1	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	003	2	2021	02	BCN Advantage HMO-POS Prestige (HMO-POS)	Michigan		Region 2	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	003	3	2021	02	BCN Advantage HMO-POS Prestige (HMO-POS)	Michigan		Region 3	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	003	4	2021	02	BCN Advantage HMO-POS Prestige (HMO-POS)	Michigan		Region 4	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	003	5	2021	02	BCN Advantage HMO-POS Prestige (HMO-POS)	Michigan		Region 5	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	007	0	2021	01	BCN Advantage HMO ConnectedCare (HMO)	Kalamazoo, Metro Detroit Area and Bay Region		Kalamazoo, Metro Detroit Area and Bay Region	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	012	1	2021	02	BCN Advantage Community Value (HMO-POS)	Metro Detroit Area, Genesee, Livingston, St. Clair		Region 1	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	012	2	2021	02	BCN Advantage Community Value (HMO-POS)	Metro Detroit Area, Genesee, Livingston, St. Clair		Region 2	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	014	1	2021	02	BCN Advantage Prime Value (HMO-POS)	Michigan		Region 1	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	014	2	2021	02	BCN Advantage Prime Value (HMO-POS)	Michigan		Region 2	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	014	3	2021	02	BCN Advantage Prime Value (HMO-POS)	Michigan		Region 3	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	014	4	2021	02	BCN Advantage Prime Value (HMO-POS)	Michigan		Region 4	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	014	5	2021	02	BCN Advantage Prime Value (HMO-POS)	Michigan		Region 5	1	0	0	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	801	0	2021	02	BCN Advantage (HMO-POS)	Employer Group		Employer Group	1	3	1	20500 Civic Center Drive		Southfield	MI	48076												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5883	805	0	2021	02	BCN Advantage (HMO-POS)	Employer Group		Employer Group	1	3	1	20500 Civic Center Drive		Southfield	MI	48076				20500 Civic Center Drive		Southfield	MI	48076				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.bcbsm.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H5902	001	0	2021	20	Senior LIFE Altoona Dual Eligible (PACE)	Blair, Indiana, and Cambria Counties		Blair, Indiana, and Cambria Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200001200300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H5902	002	0	2021	20	Senior LIFE Altoona Medicare Only (PACE)	Blair, Indiana, and Cambria Counties		Blair, Indiana, and Cambria Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H5926	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Michigan		Select Counties in Michigan	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5926	004	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Michigan		Select Counties in Michigan	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H5928	004	0	2021	01	Blue Shield AdvantageOptimum Plan (HMO)	Los Angeles and Orange Counties	Blue Shield AdvantageOptimum Plan (HMO)	Los Angeles and Orange Counties	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	005	0	2021	01	Blue Shield TotalDual Plan (HMO D-SNP)	Counties: LA, OR, SB, SD	Blue Shield TotalDual Plan (HMO D-SNP)	Counties: LA, OR, SB, SD	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	010	0	2021	01	Blue Shield AdvantageOptimum Plan 1 (HMO)	San Diego County	Blue Shield AdvantageOptimum Plan 1 (HMO)	San Diego County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	016	0	2021	01	Blue Shield AdvantageOptimum Plan (HMO)	Santa Clara County	Blue Shield AdvantageOptimum Plan (HMO)	Santa Clara County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	037	0	2021	01	Blue Shield Coordinated Choice Plan (HMO)	Counties: LA, OR, SD, SB, RV, SC, FR, ME, SJ, ST	Blue Shield Coordinated Choice Plan (HMO)	Counties: LA, OR, SD, SB, RV, SC, FR, ME, SJ, ST	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	044	0	2021	01	Blue Shield AdvantageOptimum Plan (HMO)	Fresno County	Blue Shield AdvantageOptimum Plan (HMO)	Fresno County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	050	0	2021	01	Blue Shield AdvantageOptimum Plan (HMO)	Merced County	Blue Shield AdvantageOptimum Plan (HMO)	Merced County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	051	0	2021	01	Blue Shield AdvantageOptimum Plan (HMO)	Stanislaus County	Blue Shield AdvantageOptimum Plan (HMO)	Stanislaus County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	052	0	2021	01	Blue Shield AdvantageOptimum Plan (HMO)	San Joaquin County	Blue Shield AdvantageOptimum Plan (HMO)	San Joaquin County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	053	0	2021	01	Blue Shield AdvantageOptimum Plan 2 (HMO)	San Diego County	Blue Shield AdvantageOptimum Plan 2 (HMO)	San Diego County	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5928	054	0	2021	01	Blue Shield Inspire (HMO D-SNP)	Fresno/San Joaquin/Stanislaus Counties	Blue Shield Inspire (HMO D-SNP)	Fresno/San Joaquin/Stanislaus Counties	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367				6300 Canoga Avenue		Woodland Hills	CA	91367				5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	blueshieldca.com/find-a-doctor	blueshieldca.com/medpharmacy2021	blueshieldca.com/medformulary2021
H5932	001	0	2021	01	Gateway Health Medicare Assured Diamond (HMO D-SNP)	Pennsylvania Counties		Pennsylvania Counties	1	0	0	Four Gateway Center	444 Liberty Avenue, Suite 2100	Pittsburgh	PA	15222		medicareassured@gatewayhealthplan.com	medicareassured@gatewayhealthplan.com	Four Gateway Center	444 Liberty Avenue, Suite 2100	Pittsburgh	PA	15222		medicareassured@gatewayhealthplan.com	medicareassured@gatewayhealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gatewayhealthplan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.gatewayhealthplan.com	www.gatewayhealthplan.com	www.gatewayhealthplan.com
H5932	009	0	2021	01	Gateway Health Medicare Assured Ruby (HMO D-SNP)	Pennsylvania Counties		Pennsylvania Counties	1	0	0	Four Gateway Center	444 Liberty Avenue, Suite 2100	Pittsburgh	PA	15222		medicareassured@gatewayhealthplan.com	medicareassured@gatewayhealthplan.com	Four Gateway Center	444 Liberty Avenue, Suite 2100	Pittsburgh	PA	15222		medicareassured@gatewayhealthplan.com	medicareassured@gatewayhealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.gatewayhealthplan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.gatewayhealthplan.com	www.gatewayhealthplan.com	www.gatewayhealthplan.com
H5934	001	0	2021	20	Hope PACE (PACE)	Lee, Charlotte and Collier Counties Florida		Lee, Charlotte and Collier Counties Florida	1	3	0									2668 Winkler Avenue		Fort  Myers	FL	33901		brian.mckaig@hopehcs.org	brian.mckaig@hopehcs.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopepace.org	0	0	1			0					3	0	0		carekinesis.com	hopehcs.org/pace
H5934	002	0	2021	20	Hope PACE (PACE)	Lee, Charlotte and Collier Counties Florida		Lee, Charlotte and Collier Counties Florida	1	3	0									2668 Winkler Avenue		Fort  Myers	FL	33901		brian.mckaig@hopehcs.org	brian.mckaig@hopehcs.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopepace.org	0	0	1			0					3	0	0		carekinesis.com	hopehcs.org/pace
H5937	001	0	2021	01	UCare Connect + Medicare (HMO D-SNP)	62 Counties		62 Counties	1	0	0	PO Box 52		Minneapolis	MN	55440		SNPsales@ucare.org		PO Box 52		Minneapolis	MN	55440		SNPsales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H5938	001	0	2021	01	Capital Health Plan Advantage Plus (HMO)	Leon and surrounding counties		Leon and surrounding counties	1	0	0	P.O. Box 15349		Tallahassee	FL	32317				P.O. Box 15349		Tallahassee	FL	32317				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5938	006	0	2021	01	Capital Health Plan Preferred Advantage (HMO)	Leon and surrounding counties		Leon and surrounding counties	1	0	0	P.O. Box 15349		Tallahassee	FL	32317				P.O. Box 15349		Tallahassee	FL	32317				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5938	008	0	2021	01	Capital Health Plan Silver Advantage (HMO)	Leon and surrounding counties		Leon and surrounding counties	1	0	0	P.O. Box 15349		Tallahassee	FL	32317				P.O. Box 15349		Tallahassee	FL	32317				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5938	802	0	2021	01	Capital Health Plan Retiree Advantage (HMO)	Leon and surrounding counties		Leon and surrounding counties	1	3	1	P.O. Box 15349		Tallahassee	FL	32317				P.O. Box 15349		Tallahassee	FL	32317				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5938	803	0	2021	01	Capital Health Plan Retiree Advantage (HMO)	Leon and surrounding counties		Leon and surrounding counties	1	3	1	P.O. Box 15349		Tallahassee	FL	32317												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	2	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5938	804	0	2021	01	Capital Health Plan Retiree Advantage (HMO)	Leon and surrounding counties		Leon and surrounding counties	1	3	1	P.O. Box 15349		Tallahassee	FL	32317				P.O. Box 15349		Tallahassee	FL	32317				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5938	805	0	2021	01	805 Emp-only SOF Capital Health Plan Retiree Advan (HMO)	Florida Statewide		Florida Statewide	1	3	1	P.O. Box 15349		Tallahassee	FL	32317				P.O. Box 15349		Tallahassee	FL	32317				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.capitalhealth.com/Medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare	www.capitalhealth.com/Medicare
H5943	001	0	2021	02	VillageHealth (HMO-POS C-SNP)	Riverside and  San Bernardino Counties	VillageHealth (HMO-POS C-SNP)	Riverside and  San Bernardino Counties	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.villagehealthca.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $370.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $370.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.villagehealthca.com	www.villagehealthca.com	www.villagehealthca.com
H5943	002	0	2021	02	VillageHealth (HMO-POS C-SNP)	Los Angeles County	VillageHealth (HMO-POS C-SNP)	Los Angeles County	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.villagehealthca.com	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.villagehealthca.com	www.villagehealthca.com	www.villagehealthca.com
H5945	001	0	2021	01	Prominence Plus (HMO)	Carson City, Douglas, Lyon, Storey, Churchill		Carson City, Douglas, Lyon, Storey, Churchill	1	0	0	1510 Meadow Wood Lane		Reno	NV	89502				1510 Meadow Wood Lane		Reno	NV	89502				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H5945	002	0	2021	01	Prominence Plus (HMO)	Washoe County		Washoe County	1	0	0	1510 Meadow Wood Lane		Reno	NV	89502				1510 Meadow Wood Lane		Reno	NV	89502				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H5945	008	0	2021	01	Prominence Plus (HMO)	Palm Beach		Palm Beach	1	0	0	1510 Meadow Wood Lane		Reno	NV	89502				1510 Meadow Wood Lane		Reno	NV	89502				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H5945	801	0	2021	01	Prominence Health Plan (HMO)	National		National	1	3	1	1510 Meadow Wood Lane		Reno	NV	89502												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H5945	802	0	2021	01	Prominence Health Plan (HMO)	National		National	1	3	1	1510 Meadow Wood Lane		Reno	NV	89502				1510 Meadow Wood Lane		Reno	NV	89502				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H5959	007	1	2021	04	Blue Cross Medicare Advantage Choice MA Only (PPO)	51 County Region	Blue Cross Medicare Advantage Choice MA Only (PPO)	Nine County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	007	2	2021	04	Blue Cross Medicare Advantage Choice MA Only (PPO)	51 County Region	Blue Cross Medicare Advantage Choice MA Only (PPO)	42 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	008	0	2021	04	Blue Cross Medicare Advantage Choice MA Only (PPO)	15 County Region	Blue Cross Medicare Advantage Choice MAOnly (PPO)	15 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	009	0	2021	04	Blue Cross Medicare Advantage Choice (PPO)	15 County Region	Blue Cross Medicare Advantage Choice (PPO)	15 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		Eagan	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	010	1	2021	04	Blue Cross Medicare Advantage Complete (PPO)	51 County Region	Blue Cross Medicare Advantage Complete (PPO)	Nine County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St. Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	010	2	2021	04	Blue Cross Medicare Advantage Complete (PPO)	51 County Region	Blue Cross Medicare Advantage Complete (PPO)	42 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St. Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	011	0	2021	04	Blue Cross Medicare Advantage Complete (PPO)	15 County Region	Blue Cross Medicare Advantage Complete (PPO)	15 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St. Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	012	0	2021	04	Blue Cross Medicare Advantage Core (PPO)	15 County Region	Blue Cross Medicare Advantage Core (PPO)	15 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		Eagan	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	013	1	2021	04	Blue Cross Medicare Advantage Core (PPO)	51 County Region	Blue Cross Medicare Advantage Core (PPO)	Nine County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St.Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	013	2	2021	04	Blue Cross Medicare Advantage Core (PPO)	51 County Region	Blue Cross Medicare Advantage Core (PPO)	42 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St.Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	014	1	2021	04	Blue Cross Medicare Advantage Choice (PPO)	51 County Region	Blue Cross Medicare Advantage Choice (PPO)	Nine County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St.Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	014	2	2021	04	Blue Cross Medicare Advantage Choice (PPO)	51 County Region	Blue Cross Medicare Advantage Choice (PPO)	42 County Region	1	0	0	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St.Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	801	0	2021	04	Group EGWP MAPD (PPO)	66 County region		66 County region	1	3	1	3400 Yankee Dr		Eagan	MN	55121				PO Box 64560		St.Paul	MN	55121				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5959	807	0	2021	04	Group EGWP Medical Only (PPO)	66 County Region	Group EGWP Medical Only (PPO)	66 County Region	1	3	1	3499 Yankee Drive		Eagan	MN	55121												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluecrossmnonline.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bluecrossmnonline.com	www.myprime.com	www.myprime.com
H5965	001	0	2021	04	WellCare Prime (PPO)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5965	002	0	2021	04	WellCare Premier (PPO)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5965	003	0	2021	04	WellCare Patriot (PPO)	Select counties in WA		Select counties in WA	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H5969	002	0	2021	01	AlohaCare Advantage Plus (HMO D-SNP)	State of Hawaii		State of Hawaii	1	0	0	1357 Kapiolani Blvd., Suite 1250		Honolulu	HI	96814		customerservicedistribution@alohacare.org	customerservicedistribution@alohacare.org	1357 Kapiolani Blvd., Suite 1250		Honolulu	HI	96814		customerservicedistribution@alohacare.org	customerservicedistribution@alohacare.org	7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	AlohaCare.org	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	AlohaCare.org	AlohaCare.org	AlohaCare.org
H5970	001	0	2021	04	HumanaChoice H5970-001 (PPO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	015	0	2021	04	HumanaChoice H5970-015 (PPO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	016	0	2021	04	Humana Honor (PPO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	018	0	2021	04	HumanaChoice H5970-018 (PPO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	019	0	2021	04	HumanaChoice H5970-019 (PPO)	Select Counties in New York		Select Counties in New York	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	020	0	2021	04	HumanaChoice SNP-DE H5970-020 (PPO D-SNP)	Cattaraugus, Chautauqua and Madison counties		Cattaraugus, Chautauqua and Madison counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	024	1	2021	04	HumanaChoice H5970-024 (PPO)	New York City and Long Island		Select Counties in New York City	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	024	2	2021	04	HumanaChoice H5970-024 (PPO)	New York City and Long Island		Nassau, Richmond and Suffolk counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	801	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	802	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	805	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	806	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	816	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	817	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	818	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	819	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	820	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5970	821	0	2021	04	Humana Medicare Employer (PPO)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H5978	001	0	2021	20	Senior LIFE Lehigh Valley Dual Eligible (PACE)	Northampton, Lehigh & Berks Counties		Northampton, Lehigh & Berks Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100001200200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H5978	002	0	2021	20	Senior LIFE Lehigh Valley Medicare Only (PACE)	Northampton, Lehigh & Berks Counties		Northampton, Lehigh & Berks Counties	1	3	0									401 Broad Street		Johnstown	PA	15906				2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.seniorlifepa.com	0	0	1			0					3	0	0		http://granerx.com/	NA
H5989	011	0	2021	01	Healthfirst Signature (HMO)	Most of New York City and Nassau County	Signature de Healthfirst (HMO)	Most of New York City and Nassau County	1	0	0	Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				Healthfirst Medicare Plan	PO Box 5165	New York	NY	10274				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthfirst.org/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.hfdocfinder.org	www.hfdocfinder.org	www.healthfirst.org/formularies
H5991	001	0	2021	01	EmblemHealth VIP Dual Select (HMO D-SNP)	NYC, Long Island and Hudson Valley		NYC, Long Island and Hudson Valley	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	002	0	2021	01	EmblemHealth VIP Solutions (HMO D-SNP)	NYC, Long Island, Hudson Valley, Capital Distrct		NYC, Long Island, Hudson Valley, Capital Distrct	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	003	0	2021	01	EmblemHealth VIP Passport (HMO)	Long Island and Lower Hudson Valley		Long Island and Lower Hudson Valley	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	006	0	2021	01	EmblemHealth VIP Passport NYC (HMO)	New York City, Bronx, Queens, Kings, Richmond		New York City, Bronx, Queens, Kings, Richmond	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	007	0	2021	01	EmblemHealth VIP Connect (HMO D-SNP)	New York City, Westchester and Long Island		New York City, Westchester and Long Island	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	008	0	2021	01	EmblemHealth VIP Assist (HMO D-SNP)	New York City, Westchester and Long Island		New York City, Westchester and Long Island	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	009	0	2021	01	EmblemHealth VIP Reserve (HMO)	Bronx, Kings, New York City, Queens		Bronx, Kings, New York City, Queens	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5991	010	0	2021	01	EmblemHealth VIP Dual Reserve (HMO D-SNP)	Bronx, Kings, New York City, Queens		Bronx, Kings, New York City, Queens	1	0	0	PO Box 4001		Farmington	CT	06034				PO Box 4001		Farmington	CT	06034				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	emblemhealth.com/medicare	emblemhealth.com/medicare	emblemhealth.com/medicare
H5992	007	0	2021	01	Senior Whole Health of New York NHC (HMO D-SNP)	Counties: Ki, Qu, Brx, NY, Wes, and Na		Counties: Ki, Qu, Brx, NY, Wes, and Na	1	0	0	Church St. Station	PO Box 1624	New York	NY	10008		info@seniorwholehealth.com	info@seniorwholehealth.com	Church St. Station	PO Box 1624	New York	NY	10008		info@seniorwholehealth.com	info@seniorwholehealth.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.seniorwholehealth.com	www.seniorwholehealth.com
H5995	001	0	2021	01	ATRIO Special Needs Plan (Willamette) (HMO D-SNP)	Marion and Polk Counties	ATRIO Special Needs Plan (Willamette) (HMO D-SNP)	Marion and Polk Counties	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6053	999	0	2021	19	Santa Fe Employes Hospital Assn. - Coast Lines	State of California		State of California	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.		sfeha.com	0	0	2			0					3	0	0			
H6059	001	0	2021	20	PACE of The Triad - Dual (PACE)	PACE of The Triad - Dual		PACE of The Triad - Dual	1	3	0									1471 East Cone Blvd		Greensboro	NC	27405		Ursula.Robinson@pacetriad.org	Ursula.Robinson@pacetriad.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacetriad.org	0	0	1			0					3	0	0		https://www.carekinesis.com/	N/A
H6059	002	0	2021	20	PACE of The Triad - Medicare only (PACE)	PACE of The Triad - Medicare only		PACE of The Triad - Medicare only	1	3	0									1471 East Cone Blvd		Greensboro	NC	27405		Ursula.Robinson@Pacetriad.org	Ursula.Robinson@Pacetriad.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pacetriad.org	0	0	1			0					3	0	0		https://www.carekinesis.com/	N/A
H6067	001	1	2021	01	CareFirst BlueCross BlueShield Advantage Core (HMO)	Central Maryland		Counties: AA, BA, BC, CA, FR, HA, HO	1	0	0	PO Box 3236		Scranton	PA	18505				POB 52000 MC 109		Phoenix	AZ	85072				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	https://carefirst.sapphirecareselect.com/?ci=dft-carefirstbcbsmedicareadvantagehmo	carefirst.com/medicare	carefirst.com/medicare
H6067	001	2	2021	01	CareFirst BlueCross BlueShield Advantage Core (HMO)	Central Maryland		Counties: MO, PG	1	0	0	PO Box 3236		Scranton	PA	18505				POB 52000 MC 109		Phoenix	AZ	85072				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	https://carefirst.sapphirecareselect.com/?ci=dft-carefirstbcbsmedicareadvantagehmo	carefirst.com/medicare	carefirst.com/medicare
H6067	002	1	2021	01	CareFirst BlueCross BlueShield Advantage Enhanced (HMO)	Central Maryland		Counties: AA, BA, BC, CA, FR, HA, HO	1	0	0	PO Box 3236		Scranton	PA	18505				POB 52000 MC 109		Phoenix	AZ	85072				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	https://carefirst.sapphirecareselect.com/?ci=dft-carefirstbcbsmedicareadvantagehmo	carefirst.com/medicare	carefirst.com/medicare
H6067	002	2	2021	01	CareFirst BlueCross BlueShield Advantage Enhanced (HMO)	Central Maryland		Counties: MO, PG	1	0	0	PO Box 3236		Scranton	PA	18505				POB 52000 MC 109		Phoenix	AZ	85072				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	https://carefirst.sapphirecareselect.com/?ci=dft-carefirstbcbsmedicareadvantagehmo	carefirst.com/medicare	carefirst.com/medicare
H6067	801	0	2021	01	CareFirst BlueCross BlueShield Advantage Group (HMO)	Maryland		Maryland	1	3	1	PO Box 3236		Scranton	PA	18505				POB 52000 MC 109		Phoenix	AZ	85072				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.carefirst.com/medicare	carefirstadvantage.com	carefirstadvantageformulary.com
H6067	802	0	2021	01	CareFirst BlueCross BlueShield Advantage Group (HMO)	Maryland		Maryland	1	3	1	PO Box 3236		Scranton	PA	18505												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.carefirst.com/medicare	carefirstadvantage.com	carefirstadvantageformulary.com
H6067	803	0	2021	01	CareFirst BlueCross BlueShield Advantage Group (HMO)	Maryland		Maryland	1	3	1	PO Box 3236		Scranton	PA	18505				POB 52000 MC 109		Phoenix	AZ	85072				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.carefirst.com/medicare	carefirstadvantage.com	carefirstadvantageformulary.com
H6067	804	0	2021	01	CareFirst BlueCross BlueShield Advantage Group (HMO)	Maryland		Maryland	1	3	1	PO Box 3236		Scranton	PA	18505												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	carefirst.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.carefirst.com/medicare	carefirstadvantage.com	carefirstadvantageformulary.com
H6078	801	0	2021	04	Secure Preferred (PPO)	Pennsylvania National		Pennsylvania National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BlueMedicareAdvantage.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare
H6078	802	0	2021	04	Secure Preferred (PPO)	Pennsylvania National		Pennsylvania National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BlueMedicareAdvantage.com/Medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare
H6078	803	0	2021	04	Secure Preferred (PPO)	Pennsylvania National		Pennsylvania National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BlueMedicareAdvantage.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare
H6078	804	0	2021	04	Secure Preferred (PPO)	Pennsylvania National		Pennsylvania National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BlueMedicareAdvantage.com/Medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare
H6078	805	0	2021	04	Secure Preferred (PPO)	Pennsylvania National		Pennsylvania National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BlueMedicareAdvantage.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare
H6078	806	0	2021	04	Secure Preferred (PPO)	Pennsylvania National		Pennsylvania National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	BlueMedicareAdvantage.com/Medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare	BlueMedicareAdvantage.com/Medicare
H6079	001	0	2021	20	InnovAge California PACE (PACE)	San Bernardino and Riverside counties		San Bernardino and Riverside counties	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		www.granerx.com	N/A
H6079	002	0	2021	20	InnovAge California PACE (PACE)	San Bernardino and Riverside counties		San Bernardino and Riverside counties	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		www.granerx.com	N/A
H6080	001	0	2021	48	MeridianComplete (Medicare-Medicaid Plan)	Greater Chicago		Greater Chicago	1	0	0	1 Campus Martius	Suite 700	Detroit	MI	48226				1 Campus Martius	Suite 700	Detroit	MI	48226				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	https://corp.mhplan.com/	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	https://corp.mhplan.com/	https://corp.mhplan.com/	https://corp.mhplan.com/
H6121	003	0	2021	01	Bright Advantage Assist (HMO)	Chicago Area		Chicago Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H6121	008	0	2021	01	Bright Advantage (HMO)	Chicago Area		Chicago Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H6140	999	0	2021	19	Wabash Mem. Hospital	Wabash Mem. Hospital		Wabash Mem. Hospital	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.			0	0	2			0					3	0	0			
H6142	999	0	2021	19	Union Health Service, Inc.	Union Health Service, Inc		Union Health Service, Inc	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.		www.unionhealth.org	0	0	2			0					3	0	0			
H6154	001	0	2021	02	Medica Advantage Solution H6154-001 (HMO-POS)	Minneapolis/St. Paul Metro Area		Minneapolis/St. Paul Metro Area	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	1	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H6154	002	0	2021	02	Medica Advantage Solution H6154-002 (HMO-POS)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	1	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H6154	003	0	2021	01	Medica Advantage Solution PartnerCare Premier (HMO I-SNP)	Select counties in MN		Select counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	1	1	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $140.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $140.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H6154	004	0	2021	01	Medica Advantage Solution PartnerCare Focus (HMO I-SNP)	Select counties in MN		Select counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	medica.com	1	1	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $140.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $140.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H6158	001	0	2021	01	BlueMedicare Premier (HMO)	Select Counties in Northwest, West, and Central AR		Select Counties in Northwest, West, and Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H6158	002	0	2021	01	BlueMedicare Premier (HMO)	Select Counties in West, Central, and Northeast AR		Select Counties in West, Central, and Northeast AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H6188	001	0	2021	20	VieCare Armstrong, LLC dba LIFE Armstrong County (PACE)	Armstrong County		Armstrong County	1	3	0									115 Nolte Drive Ext		Kittanning	PA	16201				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lutheranseniorlife.org	0	0	1			0					3	0	0		www.lutheranseniorlife.org	www.lutheranseniorlife.org
H6188	002	0	2021	20	VieCare Armstrong, LLC dba LIFE Armstrong County (PACE)	Armstrong County		Armstrong County	1	3	0									115 Nolte Drive Extension		Kittanning	PA	16201				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lutheranseniorlife.org	0	0	1			0					3	0	0		www.lutheranseniorlife.org	www.lutheranseniorlife.org
H6202	001	0	2021	04	NextBlue Classic PPO (PPO)	Central-East North Dakota		Central-East North Dakota	1	0	0	P.O. Box 261156		Plano	TX	75026				P.O. Box 261156		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.nextblueND.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.nextblueND.com/findadoctor	www.nextblueND.com/pharmacies	www.nextblueND.com/formularies
H6202	002	0	2021	04	NextBlue Premium PPO (PPO)	Central-East Region		Central-East Region	1	0	0	P.O. Box 261156		Plano	TX	75026				P.O. Box 261156		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.nextblueND.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.nextblueND.com/findadoctor	www.nextblueND.com/pharmacies	www.nextblueND.com/formularies
H6202	801	0	2021	04	NextBlue of North Dakota Group PPO (PPO)	State of North Dakota		State of North Dakota	1	3	1	P.O. Box 261156		Plano	TX	75026				P.O. Box 261156		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nextblueND.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.nextblueND.com/findadoctor	www.nextblueND.com/pharmacies	www.nextblueND.com/formularies
H6202	802	0	2021	04	NextBlue of North Dakota Group PPO (PPO)	State of North Dakota		State of North Dakota	1	3	1	P.O. Box 261156		Plano	TX	75026				P.O. Box 261156		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nextblueND.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.nextblueND.com/findadoctor	www.nextblueND.com/pharmacies	www.nextblueND.com/formularies
H6202	803	0	2021	04	NextBlue of North Dakota Group PPO (PPO)	State of North Dakota		State of North Dakota	1	3	1	P.O. Box 261156		Plano	TX	75026				P.O. Box 261156		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nextblueND.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.nextblueND.com/findadoctor	www.nextblueND.com/pharmacies	www.nextblueND.com/formularies
H6229	005	0	2021	48	Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)	Los Angeles County (Partial)		Los Angeles County (Partial)	1	0	0	12900 Park Plaza Drive	Suite 150	Cerritos	CA	90703				12900 Park Plaza Drive	Suite 150	Cerritos	CA	90703				5000000000208002000308002000408002000508002000608002000000000000	5100000000208002000308002000408002000508002000608002000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	duals.anthem.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	duals.anthem.com	duals.anthem.com	duals.anthem.com
H6229	006	0	2021	48	Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)	Santa Clara County		Santa Clara County	1	0	0	2868 Prospect Park Dr.	Suite 100	Rancho Cordova	CA	95670				2868 Prospect Park Dr.	Suite 100	Rancho Cordova	CA	95670				5000000000208002000308002000408002000508002000608002000000000000	5100000000208002000308002000408002000508002000608002000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	duals.anthem.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	duals.anthem.com	duals.anthem.com	duals.anthem.com
H6231	001	0	2021	20	Franciscan PACE, Inc. (PACE)	PACE Baton Rouge		PACE Baton Rouge	1	3	0									7436 Bishop Ott Drive	4200 Essen Lane	Baton Rouge	LA	70806		karen.allen@fmolhs.org	karen.allen@fmolhs.org	3000000000207301700307301700407301700507301700607301700000000000	3000000000207301700307301700407301700507301700607301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.ololrmc.com	0	0	1			0					3	0	0		www.carekinesis.com	www.ololrmc.org
H6231	002	0	2021	20	Franciscan PACE, Inc. (PACE)	PACE Baton Rouge		PACE Baton Rouge	1	3	0									7436 Bishop Ott Drive	4200 Essen Lane	Baton Rouge	LA	70806		karen.allen@fmolhs.org	karen.allen@fmolhs.org	3000000000207301700307301700407301700507301700607301700000000000	3000000000207301700307301700407301700507301700607301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fmolhs.org	0	0	1			0					3	0	0		www.carekinesis.com	www.ololrmc.org
H6237	006	0	2021	01	Regence Valiance (HMO)	Select Counties in Oregon/Clark County, WA		Select Counties in Oregon/Clark County, WA	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6237	007	1	2021	01	Regence BlueAdvantage HMO (HMO)	Select Counties in Oregon/Clark County, WA		Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6237	007	2	2021	01	Regence BlueAdvantage HMO (HMO)	Select Counties in Oregon/Clark County, WA		Lane	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6237	007	3	2021	01	Regence BlueAdvantage HMO (HMO)	Select Counties in Oregon/Clark County, WA		Deschutes	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6237	008	1	2021	01	Regence BlueAdvantage HMO Plus (HMO)	Select Counties in Oregon/Clark County, WA		Metro	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6237	008	2	2021	01	Regence BlueAdvantage HMO Plus (HMO)	Select Counties in Oregon/Clark County, WA		Lane	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6237	008	3	2021	01	Regence BlueAdvantage HMO Plus (HMO)	Select Counties in Oregon/Clark County, WA		Deschutes	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501				PO Box 1827	M/S B32G	Medford	OR	97501				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.regence.com/medicare	www.regence.com/medicare	www.regence.com/medicare
H6306	005	0	2021	01	FirstMedicare Direct smartHMO (HMO)	Wake County		Wake County	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	011	1	2021	02	FirstMedicare Direct POS Plus (HMO-POS)	North Carolina		Sandhills	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	011	3	2021	02	FirstMedicare Direct POS Plus (HMO-POS)	North Carolina		Western North Carolina	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	012	1	2021	02	FirstMedicare Direct POS Standard (HMO-POS)	North Carolina		Sandhills	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	012	5	2021	02	FirstMedicare Direct POS Standard (HMO-POS)	North Carolina		Western North Carolina	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	013	0	2021	02	New Hanover Health FirstMedicare Select (HMO-POS)	New Hanover, Pender, and Brunswick counties		New Hanover, Pender, and Brunswick counties	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	014	0	2021	02	New Hanover Health FirstMedicare Platinum (HMO-POS)	New Hanover, Pender, and Brunswick counties		New Hanover, Pender, and Brunswick counties	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6306	015	0	2021	02	FirstMedicare Direct POS Choice (HMO-POS)	Sandhills		Sandhills	1	0	0	42 Memorial Drive		Pinehurst	NC	28374												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.firstmedicare.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H6316	001	0	2021	01	Healthy Blue Essential (HMO)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	PO Box 31685		Tampa	FL	33631				PO Box 31685		Tampa	FL	33631				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.healthybluemo.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.healthybluemo.com/medicare	https://shop.healthybluemo.com/medicare	https://shop.healthybluemo.com/medicare
H6316	002	0	2021	01	Healthy Blue Dual (HMO D-SNP)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	PO Box 31685		Tampa	FL	33631				PO Box 31685		Tampa	FL	33631				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.healthybluemo.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.healthybluemo.com/medicare	https://shop.healthybluemo.com/medicare	https://shop.healthybluemo.com/medicare
H6328	001	0	2021	04	Care N' Care Choice Premium (PPO)	Dallas/Fort Worth Metro Area		Dallas/Fort Worth Metro Area	1	0	0	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	yourteam@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	yourteam@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	002	0	2021	04	Care N' Care Choice Plus (PPO)	Dallas/Fort Worth Metro Area		Dallas/Fort Worth Metro Area	1	0	0	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	003	0	2021	04	Care N' Care Choice (PPO)	Dallas/Fort Worth Metro Area		Dallas/Fort Worth Metro Area	1	0	0	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	005	0	2021	04	Care N' Care Choice MA-Only (PPO)	Dallas/Fort Worth Metro Area		Dallas/Fort Worth Metro Area	1	0	0	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	801	0	2021	04	Care N' Care Choice CY - MAPD (PPO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	802	0	2021	04	Care N' Care Choice NCY - MAPD (PPO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	803	0	2021	04	Care N' Care Choice CY - MA-Only (PPO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6328	804	0	2021	04	Care N' Care Choice NCY - MA-Only (PPO)	Nationwide		Nationwide	1	3	1	1701 River Run	Suite 402	Fort Worth	TX	76107		info@cnchealthplan.com	concierge@cnchealthplan.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cnchealthplan.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.cnchealthplan.com	www.cnchealthplan.com	www.cnchealthplan.com
H6334	999	0	2021	19	NY Hotel Trades Council and Hotel Assn. of NYC	NY Hotel Trades Council and Hotel Assn. of NYC		NY Hotel Trades Council and Hotel Assn. of NYC	1	3	0																			0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.		Hotelfunds.org	0	0	2			0					3	0	0			
H6342	001	0	2021	20	Complete Health with PACE (PACE)	Central Arkansas		Central Arkansas	1	3	0									2100 Pike Avenue		North Little Rock	AR	72114		swilliams@completehealthwithpace.org	swilliams@completehealthwithpace.org	3108002000200001200300001200400001200500001200600001200700001200	3108002000200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.completehealthwithpace.com	0	0	1			0					3	0	0		www.CareKinesis.com	https://www.completehealthwithpace.org
H6342	002	0	2021	20	Complete Health with PACE (PACE)	Central Arkansas		Central Arkansas	1	3	0									2100 Pike Avenue		North Little Rock	AR	72114		swilliams@completehealthwithpace.org	swilliams@completehealthwithpace.org	3100001200200001200300001200400001200500001200600001200700001200	3100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.completehealthwithpace.com	0	0	1			0					3	0	0		www.CareKinesis.com	https://www.completehealthwithpace.org
H6345	001	0	2021	01	PruittHealth Premier (HMO I-SNP)	NC (Partial)		NC (Partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.pruitthealthpremier.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.pruitthealthpremier.com	www.pruitthealthpremier.com	www.pruitthealthpremier.com
H6345	002	0	2021	01	PruittHealth Premier (HMO I-SNP)	South Carolina (partial)		South Carolina (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.pruitthealthpremier.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.pruitthealthpremier.com	www.pruitthealthpremier.com	www.pruitthealthpremier.com
H6348	001	0	2021	04	Allwell Medicare (PPO)	Central, Northern, Southwest & Northwest Indiana		Central, Northern, Southwest & Northwest Indiana	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H6348	002	0	2021	04	Allwell Medicare (PPO)	Northern Indiana		Northern Indiana	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H6348	801	0	2021	04	Allwell Group (PPO)	Indiana		Indiana	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H6348	802	0	2021	04	Allwell Group (PPO)	Indiana		Indiana	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	2	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H6348	803	0	2021	04	Allwell Group (PPO)	Indiana		Indiana	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.mhsindiana.com	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/findadoctor	allwell.mhsindiana.com/formulary
H6351	001	0	2021	01	Liberty Advantage (HMO I-SNP)	North Carolina (partial)		North Carolina (partial)	1	0	0	PO Box 3630		Little Rock	AR	72202		customerservice@libertyadvantageplan.com	customerservice@libertyadvantageplan.com	PO Box 3630		Little Rock	AR	72202		customerservice@libertyadvantageplan.com	customerservice@libertyadvantageplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	http://www.libertyadvantageplan.com	1	1	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	http://www.libertyadvantageplan.com	http://www.navitus.com/	http://www.libertyadvantageplan.com
H6351	003	0	2021	01	Liberty at Home (HMO I-SNP)	North Carolina (partial)		North Carolina (partial)	1	0	0	PO Box 3630		Little Rock	AR	72202		customerservice@libertyadvantageplan.com	customerservice@libertyadvantageplan.com	PO Box 3630		Little Rock	AR	72202		customerservice@libertyadvantageplan.com	customerservice@libertyadvantageplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.libertyadvantageplan.com	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	http://www.libertyadvantageplan.com	www.navitus.com	www.libertyadvantageplan.com
H6371	001	0	2021	20	Lutheran Senior Healthcare (PACE)	Lutheran Senior LIFE Hudson County		Lutheran Senior LIFE Hudson County	1	3	0									377 Jersey Avenue	Suite 310	Jersey City	NJ	07302		info@lsmnj.org	info@lsmnj.org	2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifelsmnj.org	0	0	1			0					3	0	0		www.lifelsmnj.org	www.lifelsmnj.org
H6371	002	0	2021	20	Lutheran Senior Healthcare (PACE)	Lutheran Senior LIFE Hudson County		Lutheran Senior LIFE Hudson County	1	3	0									377 Jersey Avenue	Suite 310	Jersey City	NJ	07302		info@lsmnj.org	info@lsmnj.org	2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifelsmnj.org	0	0	1			0					3	0	0		www.lifelsmnj.org	www.lifelsmnj.org
H6379	001	0	2021	01	Clear Spring Health Essential (HMO)	Metro Denver,Boulder,Ft.Collins,CO Springs, Pueblo		Metro Denver,Boulder,Ft.Collins,CO Springs, Pueblo	1	0	0	P.O. BOX 278530		Miramar	FL	33027				P.O. BOX 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H6396	001	0	2021	01	CareSource Advantage (HMO)	Region 3		Region 3	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/medicare/	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/medicare/benefits-services/pharmacy/drug-formulary/
H6396	004	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 3		Region 3	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/medicare/	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/medicare/benefits-services/pharmacy/drug-formulary/
H6396	005	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 3		Region 3	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/dsnp/	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/dsnp/pharmacy/drug-formulary/
H6396	011	0	2021	01	CareSource Advantage (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/medicare/	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/medicare/benefits-services/pharmacy/drug-formulary/
H6396	012	0	2021	01	CareSource Advantage (HMO)	Region 4		Region 4	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/medicare/	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/medicare/benefits-services/pharmacy/drug-formulary/
H6396	013	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/medicare/	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/medicare/benefits-services/pharmacy/drug-formulary/
H6396	014	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/dsnp/	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/dsnp/pharmacy/drug-formulary/
H6396	015	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 4		Region 4	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/oh/plans/dsnp/	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/oh/plans/dsnp/pharmacy/drug-formulary/
H6399	001	0	2021	01	Aetna Assure Premier Plus (HMO D-SNP)	Counties: BR,CM, ES, HD, MR, MX, MN, ON, PS, UN		Counties: BR,CM, ES, HD, MR, MX, MN, ON, PS, UN	1	0	0	7400 W Campus Rd		New Albany	OH	43054		NJSNP_MemberServices@aetna.com	NJSNP_MemberServices@aetna.com	7400 W Campus Rd		New Albany	OH	43054		NJSNP_MemberServices@aetna.com	NJSNP_MemberServices@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnabetterhealth.com/new-jersey-hmosnp	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnabetterhealth.com/new-jersey-hmosnp/find-provider	www.aetnabetterhealth.com/new-jersey-hmosnp/find-provider	www.aetnabetterhealth.com/new-jersey-hmosnp/drug-formulary
H6425	001	0	2021	20	Washington Regional Medicorp PACE of the Ozarks (PACE)	Northwest Arkansas		Northwest Arkansas	1	3	0									813 Founders Park Drive East, Suite 107		Springdale	AR	72762		paceoftheozarks@wregional.com	paceoftheozarks@wregional.com	3100001200200001200300001200400001200500001200600001200700001200	3100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wregional.com	0	0	1			0					3	0	0		https://www.collierdrug.com	N/A
H6425	002	0	2021	20	Washington Regional Medicorp PACE of the Ozarks (PACE)	Northwest Arkansas		Northwest Arkansas	1	3	0									813 Founders Park Drive East, Suite 107		Springdale	AR	72762		paceoftheozarks@wregional.com	paceoftheozarks@wregional.com	3100001200200001200300001200400001200500001200600001200700001200	3100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wregional.com	0	0	1			0					3	0	0		https://www.collierdrug.com	N/A
H6439	002	0	2021	01	WellCare Value (HMO)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6439	003	0	2021	01	WellCare Compass (HMO)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6439	004	0	2021	01	WellCare Dividend (HMO)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6446	001	0	2021	01	Allwell Medicare Select P3 (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	003	0	2021	01	Allwell Medicare Boost P3 (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	004	0	2021	01	Allwell Medicare Boost USHS (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	005	0	2021	01	Allwell Medicare Boost (HMO)	Carson City and Washoe Counties		Carson City and Washoe Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	009	0	2021	01	Allwell Medicare Select USHS (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	010	0	2021	01	Allwell Medicare (HMO)	Carson City and Washoe Counties		Carson City and Washoe Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	011	0	2021	01	Allwell Medicare Complement P3 (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	012	0	2021	01	Allwell Medicare Complement USHS (HMO)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	013	0	2021	01	Allwell Medicare Complement (HMO)	Carson City and Washoe Counties		Carson City and Washoe Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	014	0	2021	01	Allwell Dual Medicare Harmony P3 (HMO D-SNP)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	015	0	2021	01	Allwell Dual Medicare Harmony USHS (HMO D-SNP)	Clark and Nye Counties		Clark and Nye Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6446	016	0	2021	01	Allwell Dual Medicare Harmony (HMO D-SNP)	Carson City and Washoe Counties		Carson City and Washoe Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			AZ_InternetMemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.silversummithealthplan.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/findadoctor	allwell.silversummithealthplan.com/formulary
H6453	005	0	2021	01	Blue Advantage (HMO)	Northwest Parishes		Northwest Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	006	0	2021	01	Blue Advantage (HMO)	Northeast Parishes		Northeast Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	007	1	2021	01	Blue Advantage (HMO)	Baton Rouge		Ascension, East Baton Rouge	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	007	2	2021	01	Blue Advantage (HMO)	Baton Rouge		West Baton Rouge Parishes, Select Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	008	1	2021	01	Blue Advantage (HMO)	Greater New Orleans		Terrebonne, Lafourche, Greater New Orleans	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	008	2	2021	01	Blue Advantage (HMO)	Greater New Orleans		Assumption, Plaquemines, Select Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	009	1	2021	01	Blue Advantage (HMO)	North Shore		St. Tammany, Tangipahoa	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	009	2	2021	01	Blue Advantage (HMO)	North Shore		Washington	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	010	1	2021	01	Blue Advantage (HMO)	Acadiana		Rapides, Calcasieu, Greater Lafayette Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	010	2	2021	01	Blue Advantage (HMO)	Acadiana		Avoyelles, Grant, St. Mary, Southwest Parishes	1	0	0	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	801	0	2021	01	Blue Advantage (HMO)	State of Louisiana		State of Louisiana	1	3	1	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	802	0	2021	01	Blue Advantage (HMO)	State of Louisiana		State of Louisiana	1	3	1	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6453	803	0	2021	01	Blue Advantage (HMO)	State of Louisiana		State of Louisiana	1	3	1	5525 Reitz Ave		Baton Rouge	LA	70809			customerservice@blueadvantage.bcbsla.com									3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsla.com/blueadvantage	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage	www.bcbsla.com/blueadvantage
H6502	001	0	2021	04	Blue Medicare Advantage Access (PPO)	Kansas City Area		Kansas City Area	1	0	0	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.MedicareBlueKC.com	www.MedicareBlueKC.com	www.MedicareBlueKC.com
H6502	002	0	2021	04	Blue Medicare Advantage Essential (PPO)	Kansas City Area		Kansas City Area	1	0	0	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.MedicareBlueKC.com	www.MedicareBlueKC.com	www.MedicareBlueKC.com
H6502	003	0	2021	04	Blue Medicare Advantage Flex (no Part D) (PPO)	Kansas City Area		Kansas City Area	1	0	0	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MedicareBlueKC.com	www.MedicareBlueKC.com	www.MedicareBlueKC.com
H6502	801	0	2021	04	Blue Medicare Advantage Employer Group MA-CY (PPO)	Kansas City Area		Kansas City Area	1	3	1	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.BlueKCMA.com	https://www.medicarebluekc.com/	https://www.medicarebluekc.com/
H6502	802	0	2021	04	Blue Medicare Advantage Employer Group MAPD - CY (PPO)	Kansas City Area		Kansas City Area	1	3	1	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.BlueKCMA.com	https://www.medicarebluekc.com/	https://www.medicarebluekc.com/
H6502	803	0	2021	04	Blue Medicare Advantage Employer Group MAPD - BY (PPO)	Kansas City Area		Kansas City Area	1	3	1	Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		Blue Medicare Advantage	2301 Main Street	Kansas City	MO	64108		MASales@bluekc.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MedicareBlueKC.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.BlueKCMA.com	https://www.medicarebluekc.com/	https://www.medicarebluekc.com/
H6526	001	0	2021	01	AARP Medicare Advantage (HMO)	Bernalillo, Sandoval, and Valencia counties		Bernalillo, Sandoval, and Valencia counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H6526	002	0	2021	01	AARP Medicare Advantage (HMO)	Santa Fe Metro area		Santa Fe Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H6528	006	0	2021	04	UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO)	Select Counties in Georiga	UnitedHealthcare Medicare Advantage Choice Plan 1 (PPO)	Select Counties in Georiga	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H6528	031	0	2021	04	AARP Medicare Advantage Choice (PPO)	NW AR		NW AR	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H6528	032	0	2021	04	AARP Medicare Advantage Choice (PPO)	Central AR		Central AR	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H6528	033	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select counties in Alabama		Select counties in Alabama	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	P.O. Box 30770		Salt Lake City	UT	84130		Enroll@mypreferredcare.com	memberservices@mypreferredcare.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H6529	001	1	2021	01	MyTruAdvantage Select (HMO)	Select Counties in Indiana		Segment 1	1	0	0	MyTruAdvantage	PO Box 428	Columbus	IN	47202				MyTruAdvantage	PO Box 428	Columbus	IN	47202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mytruadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.mytruadvantage.com	www.mytruadvantage.com	www.mytruadvantage.com
H6529	001	2	2021	01	MyTruAdvantage Select (HMO)	Select Counties in Indiana		Segment 2	1	0	0	MyTruAdvantage	PO Box 428	Columbus	IN	47202				MyTruAdvantage	PO Box 428	Columbus	IN	47202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mytruadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.mytruadvantage.com	www.mytruadvantage.com	www.mytruadvantage.com
H6550	003	0	2021	01	Allwell Medicare (HMO)	Kansas City & Wichita Metro Areas		Kansas City & Wichita Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	004	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Kansas City and Wichita Metro Areas		Kansas City and Wichita Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	005	0	2021	01	Allwell Medicare Harmony (HMO D-SNP)	Kansas City and Wichita Metro Areas		Kansas City and Wichita Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	006	0	2021	01	Allwell Medicare Complement (HMO)	Kansas City & Wichita Metro Areas		Kansas City & Wichita Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	007	0	2021	01	Allwell Medicare Boost (HMO)	Kansas City & Wichita Metro Areas		Kansas City & Wichita Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	008	0	2021	01	Allwell Medicare Simple (HMO)	Kansas City & Wichita Metro Areas		Kansas City & Wichita Metro Areas	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	801	0	2021	01	Allwell Group (HMO)	Kansas		Kansas	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	802	0	2021	01	Allwell Group (HMO)	Kansas		Kansas	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	2	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6550	803	0	2021	01	Allwell Group (HMO)	Kansas		Kansas	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H6551	001	0	2021	20	LIFE St. Mary (PACE)	Partial Bucks County and Partial Montgomery County		Partial Bucks County and Partial Montgomery County	1	3	0									2500 Northgate Drive		Trevose	PA	19053		mleib@stmaryhealthcare.org	mleib@stmaryhealthcare.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.lifestmary.org/	0	0	1			0					3	0	0		stmaryhealthcare.org	stmaryhealthcare.org
H6551	002	0	2021	20	LIFE St. Mary (PACE)	Partial Bucks County and Partial Montgomery County		Partial Bucks County and Partial Montgomery County	1	3	0									2500 Northgate Drive		Trevose	PA	19053		mleib@stmaryhealthcare.org	mleib@stmaryhealthcare.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifestmary.org	0	0	1			0					3	0	0		stmaryhealthcare.org	stmaryhealthcare.org
H6594	001	0	2021	04	WellCare Premier (PPO)	Select counties in VT		Select counties in VT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6594	002	0	2021	04	WellCare Absolute (PPO)	Select counties in VT		Select counties in VT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6594	003	0	2021	04	WellCare Plus (PPO)	Select counties in VT		Select counties in VT	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6595	002	1	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H6595	002	2	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H6596	001	0	2021	20	Fallon Health Weinberg-PACE (PACE)	Erie County		Erie County	1	3	0									461 John James Audubon Pkwy.		Amherst	NY	14228				2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonweinberg.org	0	0	1			0					3	0	0	fallonweinberg.org	Notapplicable	fallonweinberg.org
H6596	002	0	2021	20	Fallon Health Weinberg-PACE (PACE)	Erie County		Erie County	1	3	0									461 John James Audubon Pkwy.		Amherst	NY	14228				2000000000208301700308301700408301700508301700608301700000000000	2000000000208301700308301700408301700508301700608301700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonweinberg.org	0	0	1			0					3	0	0	fallonweinberg.org	Notapplicable	fallonweinberg.org
H6622	001	0	2021	01	Humana Gold Plus H6622-001 (HMO)	Green Bay area		Green Bay area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	002	0	2021	01	Humana Gold Plus H6622-002 (HMO)	Milwaukee area		Milwaukee area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	004	0	2021	01	Humana Gold Plus H6622-004 (HMO)	Richmond Metro Area		Richmond Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	005	0	2021	01	Humana Gold Plus H6622-005 (HMO)	Tidewater Area		Tidewater Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	007	0	2021	01	Humana Gold Plus H6622-007 (HMO)	Select Counties in Montana		Select Counties in Montana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	008	0	2021	01	Humana Gold Plus SNP-DE H6622-008 (HMO D-SNP)	Select Counties in Montana		Select Counties in Montana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	010	0	2021	01	Humana Gold Plus H6622-010 (HMO)	Kent, New Castle and Sussex Counties		Kent, New Castle and Sussex Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	011	0	2021	01	Humana Gold Plus H6622-011 (HMO)	Cleveland Metro Area		Cleveland Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	013	0	2021	01	Humana Gold Plus H6622-013 (HMO)	Columbus Metro Area		Columbus Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	014	0	2021	01	Humana Gold Plus H6622-014 (HMO)	Canton-Akron Metro Areas		Canton-Akron Metro Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	015	0	2021	01	Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	016	0	2021	01	Humana Gold Plus H6622-016 (HMO)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	017	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Cincinnati and Columbus area		Cincinnati and Columbus area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	018	0	2021	01	Humana Gold Plus SNP-DE H6622-018 (HMO D-SNP)	Northern Kentucky Area		Northern Kentucky Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	019	0	2021	01	Humana Gold Plus H6622-019 (HMO)	Select Counties in Ohio and Kentucky		Select Counties in Ohio and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	021	1	2021	01	Humana Gold Plus H6622-021 (HMO)	Select KY counties in Cincinnati Metro Area		Select KY counties in Cincinnati Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	021	2	2021	01	Humana Gold Plus H6622-021 (HMO)	Select KY counties in Cincinnati Metro Area		Cincinnati/Dayton	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	022	0	2021	01	Humana Gold Plus H6622-022 (HMO)	Select counties in Cleveland		Select counties in Cleveland	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	023	0	2021	01	Humana Cleveland Clinic Preferred (HMO)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	025	0	2021	02	Humana Gold Plus H6622-025 (HMO-POS)	Western North Carolina Area		Western North Carolina Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $215.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $215.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	026	0	2021	01	Humana Gold Plus H6622-026 (HMO)	Western North Carolina Area		Western North Carolina Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	027	0	2021	01	Humana Gold Plus SNP-DE H6622-027 (HMO D-SNP)	Western North Carolina Area		Western North Carolina Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	028	0	2021	01	Humana Gold Plus H6622-028 (HMO)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	029	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	030	0	2021	01	Humana Gold Plus Lung (HMO C-SNP)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	032	0	2021	01	Humana Gold Plus H6622-032 (HMO)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	033	0	2021	01	Humana Gold Plus H6622-033 (HMO)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	034	0	2021	01	Humana Gold Plus H6622-034 (HMO)	Milwaukee area		Milwaukee area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	035	0	2021	01	Humana Gold Plus H6622-035 (HMO)	Central-Western Pennsylvania area		Central-Western Pennsylvania area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	036	0	2021	01	Humana Gold Plus H6622-036 (HMO)	Northeast Pennsylvania Area		Northeast Pennsylvania Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	037	0	2021	01	Humana Gold Plus H6622-037 (HMO)	Greater Philadelphia Metro Area		Greater Philadelphia Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	038	0	2021	01	Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)	Select counties in Pennsylvania		Select counties in Pennsylvania	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	040	0	2021	01	Humana Gold Plus H6622-040 (HMO)	Milwaukee area		Milwaukee area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $315.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $315.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	041	0	2021	01	Humana Gold Plus H6622-041 (HMO)	Virginia		Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	047	0	2021	01	Humana Gold Plus H6622-047 (HMO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	048	0	2021	01	Humana Gold Plus SNP-DE H6622-048 (HMO D-SNP)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	049	0	2021	01	Humana Value Plus H6622-049 (HMO)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	051	0	2021	01	Humana Gold Plus SNP-DE H6622-051 (HMO D-SNP)	Kent, New Castle and Sussex Counties		Kent, New Castle and Sussex Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	052	0	2021	01	Humana Gold Plus H6622-052 (HMO)	Guthrie and Susquehanna Valley HMO		Guthrie and Susquehanna Valley HMO	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	054	0	2021	01	Humana Gold Plus H6622-054 (HMO)	Greater Pittsburgh Area		Greater Pittsburgh Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	055	0	2021	01	Humana Gold Plus H6622-055 (HMO)	Select counties in Ohio		Select counties in Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	056	0	2021	01	Humana Gold Plus H6622-056 (HMO)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	057	0	2021	01	Humana Gold Plus H6622-057 (HMO)	Charlotte Metro Area		Charlotte Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	059	0	2021	01	Humana Gold Plus H6622-059 (HMO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	060	0	2021	01	Humana Gold Plus H6622-060 (HMO)	Triangle Perimeter		Triangle Perimeter	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	061	0	2021	01	Humana Gold Plus H6622-061 (HMO)	Wilmington		Wilmington	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	062	0	2021	02	Humana Gold Plus H6622-062 (HMO-POS)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	063	0	2021	01	Humana Gold Plus H6622-063 (HMO)	Select Counties in New Jersey		Select Counties in New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	064	0	2021	01	Humana Value Plus H6622-064 (HMO)	Clark and Nye (partial) counties		Clark and Nye (partial) counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	066	0	2021	01	Humana Gold Plus H6622-066 (HMO)	Southern New Jersey		Southern New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	069	0	2021	01	Humana Gold Plus H6622-069 (HMO)	Columbus Metro Area		Columbus Metro Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	070	0	2021	01	Humana Gold Plus H6622-070 (HMO)	Canton-Akron Metro Areas		Canton-Akron Metro Areas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	071	0	2021	01	Humana Gold Plus - Diabetes and Heart (HMO C-SNP)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	4	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	072	0	2021	01	Humana Gold Plus H6622-072 (HMO)	Richmond - Tidewater Area		Richmond - Tidewater Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $415.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $415.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	073	0	2021	02	Humana Gold Plus H6622-073 (HMO-POS)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	801	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Multi States		Select counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	802	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Multi States		Select counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	804	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Multi States		Select counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6622	805	0	2021	01	Humana Medicare Employer (HMO)	Select counties in Multi States		Select counties in Multi States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H6652	001	0	2021	01	American Health Advantage of Florida (HMO I-SNP)	Central/East Florida		Central/East Florida	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	fl.amhealthplans.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	fl.amhealthplans.com	fl.amhealthplans.com	fl.amhealthplans.com
H6672	001	0	2021	01	Clear Spring Health Deluxe Plan (HMO D-SNP)	Select Georgia Counties		Select Georgia Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H6672	003	0	2021	01	Clear Spring Health Silver Plan (HMO C-SNP)	Select Georgia Counties		Select Georgia Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	1	4	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H6672	004	0	2021	01	Clear Spring Health Select (HMO)	Select Georgia Counties		Select Georgia Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H6672	005	0	2021	01	Clear Spring Health Select Plus (HMO)	Select Georgia Counties		Select Georgia Counties	1	0	0	P.O. BOX 278530		Miramar	FL	33027				P.O. BOX 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H6706	001	0	2021	01	AARP Medicare Advantage (HMO)	Boulder County		Boulder County	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H6713	001	0	2021	04	WellCare Premier (PPO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6713	002	0	2021	04	WellCare Absolute (PPO)	Select counties in IL		Select counties in IL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6723	001	1	2021	01	MedMutual Advantage Classic (HMO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	001	2	2021	01	MedMutual Advantage Classic (HMO)	Ohio Regions		Region 2	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	001	3	2021	01	MedMutual Advantage Classic (HMO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	002	1	2021	01	MedMutual Advantage Choice (HMO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	002	2	2021	01	MedMutual Advantage Choice (HMO)	Ohio Regions		Region 2	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	002	3	2021	01	MedMutual Advantage Choice (HMO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	003	1	2021	01	MedMutual Advantage Plus (HMO)	Ohio Regions		Region 1	1	0	0	PO Box 94563		Cleveland	OH	44101				PO Box 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	003	2	2021	01	MedMutual Advantage Plus (HMO)	Ohio Regions		Region 2	1	0	0	PO Box 94563		Cleveland	OH	44101				PO Box 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	003	3	2021	01	MedMutual Advantage Plus (HMO)	Ohio Regions		Region 3	1	0	0	PO Box 94563		Cleveland	OH	44101				PO Box 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $55.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $55.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	005	1	2021	01	MedMutual Advantage Secure (HMO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	005	2	2021	01	MedMutual Advantage Secure (HMO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	006	1	2021	01	MedMutual Advantage Signature (HMO)	Ohio Regions		Region 1	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	006	2	2021	01	MedMutual Advantage Signature (HMO)	Ohio Regions		Region 3	1	0	0	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medmutual.com/planfinder	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	providersearch.medmutual.com	medmutual.com/maplaninfo	medmutual.com/maplaninfo
H6723	801	0	2021	01	MedMutual Advantage EGWP (Calendar Year) (HMO)	Ohio Regions		Ohio Regions	1	3	1	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medmutual.com/magroup	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	providersearch.medmutual.com	medmutual.com/magroup	medmutual.com/magroup
H6723	802	0	2021	01	MedMutual Advantage EGWP (Non-Calendar Year) (HMO)	Ohio Regions		Ohio Regions	1	3	1	PO BOX 94563		Cleveland	OH	44101				PO BOX 94563		Cleveland	OH	44101				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medmutual.com/magroup	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	providersearch.medmutual.com	medmutual.com/magroup	medmutual.com/magroup
H6723	803	0	2021	01	MedMutual Advantage EGWP (MA-Only) (HMO)	Ohio Regions		Ohio Regions	1	3	1	PO BOX 94563		Cleveland	OH	44101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medmutual.com/magroup	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	providersearch.medmutual.com	medmutual.com/magroup	medmutual.com/magroup
H6743	001	0	2021	04	ATRIO Bronze Rx (Basin) (PPO)	Klamath County	ATRIO Bronze Rx (Basin) (PPO)	Klamath County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	007	0	2021	04	ATRIO Bronze Rx (Umpqua) (PPO)	Douglas County	ATRIO Bronze Rx (Umpqua) (PPO)	Douglas County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	018	1	2021	04	ATRIO Bronze Rx (Rogue) (PPO)	Jackson and Josephine Counties	ATRIO Bronze Rx (Rogue) (PPO)	Jackson County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	018	3	2021	04	ATRIO Bronze Rx (Rogue) (PPO)	Jackson and Josephine Counties	ATRIO Bronze Rx (Rogue) (PPO)	Josephine County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	019	2	2021	04	ATRIO Silver (PPO)	Douglas and Klamath counties		Douglas County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	019	4	2021	04	ATRIO Silver (PPO)	Douglas and Klamath counties		Klamath County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	020	1	2021	04	ATRIO Silver Rx (PPO)	Douglas, Jackson, Josephine, and Klamath counties		Jackson County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	020	2	2021	04	ATRIO Silver Rx (PPO)	Douglas, Jackson, Josephine, and Klamath counties		Douglas County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	020	3	2021	04	ATRIO Silver Rx (PPO)	Douglas, Jackson, Josephine, and Klamath counties		Josephine County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	020	4	2021	04	ATRIO Silver Rx (PPO)	Douglas, Jackson, Josephine, and Klamath counties		Klamath County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	021	2	2021	04	ATRIO Gold Rx (PPO)	Douglas and Klamath counties		Douglas County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	021	4	2021	04	ATRIO Gold Rx (PPO)	Douglas and Klamath counties		Klamath County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	022	1	2021	04	ATRIO Bronze (PPO)	Douglas, Jackson, and Klamath counties		Jackson County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	022	2	2021	04	ATRIO Bronze (PPO)	Douglas, Jackson, and Klamath counties		Douglas County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6743	022	4	2021	04	ATRIO Bronze (PPO)	Douglas, Jackson, and Klamath counties		Klamath County	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	atriohp.com	atriohp.com	atriohp.com
H6750	005	0	2021	01	Harvard Pilgrim Stride Basic Rx (HMO)	New Hampshire		New Hampshire	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	006	0	2021	01	Harvard Pilgrim Stride Basic Rx (HMO)	Barnstable County MA		Barnstable County MA	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	007	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Barnstable County MA		Barnstable County MA	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	008	0	2021	01	Harvard Pilgrim Stride Value Rx Plus (HMO)	Barnstable County MA		Barnstable County MA	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	009	0	2021	01	Harvard Pilgrim Stride Gain Rx (HMO)	New Hampshire		New Hampshire	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	012	1	2021	01	Harvard Pilgrim Stride Value Rx Plus (HMO)	New Hampshire		Strafford County NH	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $270.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $270.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	012	2	2021	01	Harvard Pilgrim Stride Value Rx Plus (HMO)	New Hampshire		Most New Hampshire Counties	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $270.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $270.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	013	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	New Hampshire		New Hampshire	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $270.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $270.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	014	0	2021	02	Harvard Pilgrim Stride Choice Rx (HMO-POS)	New Hampshire		New Hampshire	1	0	0	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $270.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $270.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	803	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	New Hampshire		New Hampshire	1	3	1	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	804	0	2021	01	Harvard Pilgrim Stride Value Rx (HMO)	Barnstable County MA		Barnstable County MA	1	3	1	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6750	805	0	2021	02	Harvard Pilgrim Stride Choice Rx (HMO-POS)	New Hampshire		New Hampshire	1	3	1	1600 Crown Colony Drive		Quincy	MA	02169				1600 Crown Colony Drive		Quincy	MA	02169				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.hpforlife.org	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare	www.harvardpilgrim.org/medicare
H6776	001	0	2021	01	RiverSpring Star (HMO I-SNP)	Counties: Brx, Ki, Na, NY, Qu, Ri, Wes		Counties: Brx, Ki, Na, NY, Qu, Ri, Wes	1	0	0	80 West 225th Street		Bronx	NY	10463				MeridianRx	1 Campus Martius, Suite 750	Detroit	MI	48226		info@meridianrx.com	info@meridianrx.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	riverspringstar.org	1	1	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	0	riverspringstar.org	riverspringstar.org	riverspringstar.org
H6776	002	0	2021	01	RiverSpring MAP (HMO D-SNP)	Counties: Brx, Ki, Na, NY, Qu, Ri, Wes		Counties: Brx, Ki, Na, NY, Qu, Ri, Wes	1	0	0	80 West 225th Street		Bronx	NY	10463				MeridianRx	1001 Woodward Avenue, Suite 700	Detroit	MI	48226		info@meridianrx.com	info@meridianrx.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	riverspringMAP.org	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	riverspringMAP.org	riverspringMAP.org	riverspringMAP.org
H6787	001	0	2021	20	VOANS Senior Community Care of Michigan (PACE)	Ingham, Eaton, and Clinton Counties		Ingham, Eaton, and Clinton Counties	1	3	0									1921 East Miller Road		Lansing	MI	48911		bmattson@voa.org	bmattson@voa.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001800000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://seniorcommunitycaremi.org	0	0	1			0					3	0	0		http://seniorcommunitycaremi.org	http://seniorcommunitycaremi.org
H6787	002	0	2021	20	VOANS Senior Community Care of Michigan (PACE)	Eaton, Ingham and Clinton County		Eaton, Ingham and Clinton County	1	3	0									1921 East Miller Road		Lansing	MI	48911		bmattson@voa.org	bmattson@voa.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://seniorcommunitycaremi.org	0	0	1			0					3	0	0		http://seniorcommunitycaremi.org	http://seniorcommunitycaremi.org
H6815	005	0	2021	01	Health Net Ruby (HMO)	Jackson and Josephine Counties	Health Net Ruby (HMO)	Jackson and Josephine Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H6815	006	0	2021	01	Health Net Ruby (HMO)	Coos, Crook, Deschutes and Jefferson counties		Coos, Crook, Deschutes and Jefferson counties	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H6815	037	0	2021	01	Health Net Medicare Complement (HMO)	Northern and Southern Oregon		Northern and Southern Oregon	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H6815	038	0	2021	01	Health Net Ruby (HMO)	OR Counties BE, CK, CO, LA, LN, ML, MN, PK, WA, YM	Health Net Ruby (HMO)	OR Counties BE, CK, CO, LA, LN, ML, MN, PK, WA, YM	1	0	0	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	PO Box 10420		Van Nuys	CA	91410			OR_MemberInquiries@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/findadoctor	or.healthnetadvantage.com/formulary
H6815	801	0	2021	01	Health Net Seniority Plus Employer (HMO)	Oregon and California		Oregon and California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H6815	802	0	2021	01	Health Net Seniority Plus Employer (HMO)	Oregon and California		Oregon and California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H6815	803	0	2021	01	Health Net Seniority Plus Employer (HMO)	Oregon and California		Oregon and California	1	3	1	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	PO Box 10420		Van Nuys	CA	91410			member_services@healthnet.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	or.healthnetadvantage.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	or.healthnetadvantage.com/find-doctor1	or.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy	or.healthnetadvantage.com/prescription-drugs-formulary/formulary
H6830	001	0	2021	04	Ascension Complete Via Christi Access (PPO)	Butler, Harvey and Sedgwick Counties		Butler, Harvey and Sedgwick Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.ascensioncomplete.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.ascensioncomplete.com/ks-findadoctor	www.ascensioncomplete.com/ks-findadoctor	www.ascensioncomplete.com/ks-formulary
H6832	001	0	2021	01	Align Thrive (HMO I-SNP)	Michigan (partial)		Michigan (partial)	1	0	0	10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.alignseniorcare.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignseniorcare.com	www.PLACEHOLDER.com	www.PLACEHOLDER.com
H6832	002	0	2021	01	Align Connect (HMO C-SNP)	Michigan (partial)		Michigan (partial)	1	0	0	10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				10900 Nuckols Road, Suite 110		Glen Allen	VA	23060				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.alignseniorcare.com	1	4	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.alignseniorcare.com	www.PLACEHOLDER.com	www.PLACEHOLDER.com
H6846	001	0	2021	20	CarePartners PACE (PACE)	Buncombe and Henderson Counties		Buncombe and Henderson Counties	1	3	0									286 Overlook Road		Asheville	NC	28803				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://missionhealth.org/services-treatments	0	0	1			0					3	0	0		http://www.missionpardeehealthcampus.org/services/	www.Missionhealth.org
H6846	002	0	2021	20	CarePartners PACE (PACE)	Buncombe and Henderson Counties		Buncombe and Henderson Counties	1	3	0									286 Overlook Road		Asheville	NC	28803				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://missionhealth.org/services-treatments	0	0	1			0					3	0	0		http://www.missionpardeehealthcampus.org/services/	www.Missionhealth.org
H6870	001	0	2021	48	Superior HealthPlan STAR+PLUS Medicare-Medicaid (Medicare-Medicaid Plan)	Bexar, Dallas and Hidalgo Counties		Bexar, Dallas and Hidalgo Counties	1	0	0	Forum II Building	7990 IH 10 West, Ste. 300	San Antonio	TX	78230				Forum II Building	7990 IH 10 West, Ste. 300	San Antonio	TX	78230				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	mmp.superiorhealthplan.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	mmp.superiorhealthplan.com/findadoctor	mmp.superiorhealthplan.com/findadoctor	mmp.superiorhealthplan.com/formulary
H6874	001	0	2021	04	Essential Rx (PPO)	Central WI: 18 counties		Central WI: 18 counties	1	0	0	PO BOX 51		Minneapolis	MN	55440		medicaresalesMA@aspirushealthplan.com		PO BOX 51		Minneapolis	MN	55440		medicaresalesMA@aspirushealthplan.com		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aspirushealthplan.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.ucare.org	www.ucare.org
H6874	002	0	2021	04	Elite Rx (PPO)	Central WI: 18 counties		Central WI: 18 counties	1	0	0	PO BOX 51		Minneapolis	MN	55440		medicaresalesMA@aspirushealthplan.com		PO BOX 51		Minneapolis	MN	55440		medicaresalesMA@aspirushealthplan.com		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aspirushealthplan.com/medicare	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.ucare.org	www.ucare.org
H6874	003	0	2021	04	Elite (PPO)	Central WI: 18 counties		Central WI: 18 counties	1	0	0	PO BOX 51		Minneapolis	MN	55440		medicaresalesMA@aspirushealthplan.com	medicaresalesMA@aspirushealthplan.com									3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aspirushealthplan.com/medicare	0	0	2	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0		www.ucare.org	www.ucare.org
H6887	001	0	2021	20	Inspira Health Network LIFE (PACE)	Inspira Health Network LIFE		Inspira Health Network LIFE	1	3	0									2445 Delsea Drive		Vineland	NJ	08360		stevensong@ihn.org	stevensong@ihn.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.inspirahealthnetwork.org/life-center	0	0	1			0					3	0	0		http://www.inspirahealthnetwork.org/	http://www.inspirahealthnetwork.org/
H6887	002	0	2021	20	Inspira Health Network LIFE (PACE)	Inspira Health Network LIFE		Inspira Health Network LIFE	1	3	0									2445 Delsea Drive		Vineland	NJ	08360		munyans@ihn.org	munyans@ihn.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.inspirahealthnetwork.org/life-center	0	0	1			0					3	0	0		http://www.inspirahealthnetwork.org/	http://www.inspirahealthnetwork.org/
H6891	001	0	2021	01	American Health Advantage of Texas (HMO I-SNP)	Northeast Texas and Lubbock County		Northeast Texas and Lubbock County	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	tx.amhealthplans.com	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	tx.amhealthplans.com	tx.amhealthplans.com	tx.amhealthplans.com
H6898	001	0	2021	04	Vermont Blue Advantage Freedom PPO (PPO)	State of Vermont		State of Vermont	1	0	0	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H6898	002	0	2021	04	Vermont Blue Advantage Freedom Plus PPO (PPO)	State of Vermont		State of Vermont	1	0	0	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H6898	801	0	2021	04	Vermont Blue Advantage Group PPO (PPO)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H6898	802	0	2021	04	Vermont Blue Advantage Group PPO (PPO)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H6898	803	0	2021	04	Vermont Blue Advantage Group PPO (PPO)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H6910	001	0	2021	01	MediGold Essential Care (HMO)	Greater Boise Idaho		Greater Boise Idaho	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H6910	002	0	2021	01	MediGold True Advantage (HMO)	Greater Boise Idaho		Greater Boise Idaho	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H6910	003	0	2021	01	MediGold Classic Preferred (HMO)	Greater Boise Idaho		Greater Boise Idaho	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213				6150 E. Broad St, EE320		Columbus	OH	43213				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H6910	004	0	2021	01	MediGold Medical Only (HMO)	Greater Boise Idaho		Greater Boise Idaho	1	0	0	6150 E. Broad St, EE320		Columbus	OH	43213												4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MediGold.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.MediGold.com	www.MediGold.com	www.MediGold.com
H6936	003	0	2021	01	BluePathway Plan 2 (HMO)	Maricopa County		Maricopa County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H6936	004	0	2021	01	BluePathway Plan 3 (HMO)	Maricopa County		Maricopa County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H6936	005	0	2021	01	BluePathway Plan 2 (HMO)	Pima County		Pima County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H6936	006	0	2021	01	BluePathway Plan 1 (HMO)	Maricopa County		Maricopa County	1	0	0	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	13985 W. Grand Ave	Suite 200	Surprise	AZ	85374		ContactAdvantage@azblue.com	ContactAdvantage@azblue.com	4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	azbluemedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	azbluemedicare.com	azbluemedicare.com	azbluemedicare.com
H6941	001	0	2021	20	LIFE PACE Dual Eligible 001 (PACE)	Tulsa County and portions of Creek County		Tulsa County and portions of Creek County	1	3	0									5330 E. 31st Street		Tulsa	OK	74135				3000000000209001700309001700409001700509001700609001700000000000	3000000000209001700309001700409001700509001700609001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifepace.org	0	0	1			0					3	0	0		www.carekinesis.com	www.lifepace.org
H6941	002	0	2021	20	LIFE PACE Medicare Only 002 (PACE)	Tulsa County and portions of Creek County		Tulsa County and portions of Creek County	1	3	0									5330 E. 31st Street		Tulsa	OK	74135				3000000000209001700309001700409001700509001700609001700000000000	3000000000209001700309001700409001700509001700609001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.lifepace.org	0	0	1			0					3	0	0		www.carekinesis.com	www.lifepace.org
H6959	001	0	2021	01	KeyCare Advantage (HMO I-SNP)	Maryland (partial)		Maryland (partial)	1	0	0	8028 Ritchie HIghway	Suite 210	Pasadena	MD	21122				8028 Ritchie HIghway	Suite 210	Pasadena	MD	21122				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.keycareadvantage.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.keycareadvantage.com	www.keycareadvantage.com	www.keycareadvantage.com
H6975	001	0	2021	01	WellCare Value (HMO)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6975	002	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6975	003	0	2021	01	WellCare Compass (HMO)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6975	004	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6975	005	0	2021	01	WellCare Essential (HMO)	Select counties in AL		Select counties in AL	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H6988	001	0	2021	01	Centers Plan for Medicare Advantage Care (HMO)	NYC Metro Area, ERIE, NASS, NIAG, ROCK Counties		NYC Metro Area, ERIE, NASS, NIAG, ROCK Counties	1	0	0	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.centersplan.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.centersplan.com	www.centersplan.com	www.centersplan.com
H6988	002	0	2021	01	Centers Plan for Dual Coverage Care (HMO D-SNP)	Kings,Queens,Bronx,Manhattan and Richmond Counties		Kings,Queens,Bronx,Manhattan and Richmond Counties	1	0	0	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.centersplan.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.centersplan.com	www.centersplan.com	www.centersplan.com
H6988	003	0	2021	01	Centers Plan for Nursing Home Care (HMO I-SNP)	NYC Metro, ER, NA, SU, RO, WE, NI, Counties		NYC Metro, ER, NA, SU, RO, WE, NI, Counties	1	0	0	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.centersplan.com	1	1	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.centersplan.com	www.centersplan.com	www.centersplan.com
H6988	004	0	2021	01	Centers Plan for Medicaid Advantage Plus (HMO D-SNP)	NYC Metro Area, NASS, ROCK County		NYC Metro Area, NASS, ROCK County	1	0	0	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.centersplan.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.centersplan.com	www.centersplan.com	www.centersplan.com
H6988	005	0	2021	01	Centers Plan for Medicaid Advantage (HMO D-SNP)	Kings,Queens,Bronx,Manhattan and Richmond Counties		Kings,Queens,Bronx,Manhattan and Richmond Counties	1	0	0	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.centersplan.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.centersplan.com	www.centersplan.com	www.centersplan.com
H6988	801	0	2021	01	Centers Plan for Employer Groups (HMO)	NYC Metro Area, ERIE, NASS, NIAG, ROCK Counties		NYC Metro Area, ERIE, NASS, NIAG, ROCK Counties	1	3	1	75 Vanderbilt Avenue		Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	75 Vanderbilt Avenue	Suite 600	Staten Island	NY	10304		prospectivemembers@centersplan.com	memberservices@centersplan.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.centersplan.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.centersplan.com	www.centersplan.com	www.centersplan.com
H7003	001	0	2021	20	PACE Nebraska (PACE)	Select Zip Codes in DO, SA, and W, DG, C, and SU		Select Zip Codes in DO, SA, and W, DG, C, and SU	1	3	0									5755 Sorensen Parkway		Omaha	NE	68152		sgroth@immanuel.com	sgroth@immanuel.com	3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Immanuel.com	0	0	1			0					3	0	0		http://www.immanuelpathways.org/	www.immanuelpathways,org
H7003	002	0	2021	20	PACE Nebraska (PACE)	Select Zip Codes in DO, SA, and W, DG, C, and SU		Select Zip Codes in DO, SA, and W, DG, C, and SU	1	3	0									5755 Sorensen Parkway		Omaha	NE	68152		sgroth@immanuel.com	sgroth@immanuel.com	3108001630208001630308001630408001630508001630608001630000000000	3108001630208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	immanuelpathways.org	0	0	1			0					3	0	0		http://www.immanuelpathways.org/	www.immanuelpathways,org
H7006	001	0	2021	04	ATRIO Gold Rx (Willamette) (PPO)	Marion and Polk Counties	ATRIO Gold Rx (Willamette) (PPO)	Marion and Polk Counties	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1					3	0	0	atriohp.com	atriohp.com	atriohp.com
H7006	003	0	2021	04	ATRIO Silver Rx (Willamette) (PPO)	Marion and Polk Counties	ATRIO Silver Rx (Willamette) (PPO)	Marion and Polk Counties	1	0	0	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	2965 Ryan Dr SE		Salem	OR	97301		customerservice@atriohp.com	customerservice@atriohp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	atriohp.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	atriohp.com	atriohp.com	atriohp.com
H7020	004	0	2021	01	Cigna Preferred Medicare (HMO)	South Carolina	Cigna Preferred Medicare (HMO)	South Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7020	005	0	2021	01	Cigna Fundamental Medicare (HMO)	South Carolina	Cigna Fundamental Medicare (HMO)	South Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7020	006	0	2021	01	Cigna Preferred Plus Medicare (HMO)	South Carolina	Cigna Preferred Plus Medicare (HMO)	South Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7020	007	0	2021	01	Cigna Preferred Savings Medicare (HMO)	South Carolina	Cigna Preferred Savings Medicare (HMO)	South Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7020	008	0	2021	01	Cigna Preferred Medicare (HMO)	South Carolina	Cigna Preferred Medicare (HMO)	South Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7020	801	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide SC	Cigna Preferred Medicare (HMO)	Statewide SC	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7063	001	0	2021	04	Blue Medicare Advantage (PPO)	Topeka Region (DG, JA, JF, OS, PT, SN, WB)		Topeka Region (DG, JA, JF, OS, PT, SN, WB)	1	0	0	1133 SW Topeka Blvd		Topeka	KS	66629				1133 SW Topeka Blvd		Topeka	KS	66629				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsks.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.bcbsks.com/medicare	www.MyPrime.com	www.bcbsks.com/medicare
H7063	002	0	2021	04	Blue Medicare Advantage Comprehensive (PPO)	Topeka Region (DG, JA, JF, OS, PT, SN, WB)		Topeka Region (DG, JA, JF, OS, PT, SN, WB)	1	0	0	1133 SW Topeka Blvd		Topeka	KS	66629				1133 SW Topeka Blvd		Topeka	KS	66629				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsks.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.bcbsks.com/medicare	www.MyPrime.com	www.bcbsks.com/medicare
H7063	006	0	2021	04	Blue Medicare Advantage (PPO)	Wichita Region (BU, CL, HV, KM, RN, SG, SU)		Wichita Region (BU, CL, HV, KM, RN, SG, SU)	1	0	0	1133 SW Topeka Blvd		Topeka	KS	66629				1133 SW Topeka Blvd		Topeka	KS	66629				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsks.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.bcbsks.com/medicare	www.MyPrime.com	www.bcbsks.com/medicare
H7063	007	0	2021	04	Blue Medicare Advantage Comprehensive (PPO)	Wichita Region (BU, CL, HV, KM, RN, SG, SU)		Wichita Region (BU, CL, HV, KM, RN, SG, SU)	1	0	0	1133 SW Topeka Blvd		Topeka	KS	66629				1133 SW Topeka Blvd		Topeka	KS	66629				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsks.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.bcbsks.com/medicare	www.MyPrime.com	www.bcbsks.com/medicare
H7063	801	0	2021	04	MAPD Group Plan Calendar Year (PPO)	Nationwide		Nationwide	1	3	1	1133 SW Topeka Blvd		Topeka	KS	66629				1133 SW Topeka Blvd		Topeka	KS	66629				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsks.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.bcbsks.com/medicare	www.MyPrime.com	www.bcbsks.com/medicare
H7063	802	0	2021	04	MAPD Group Plan Calendar Year (PPO)	Nationwide		Nationwide	1	3	1	1133 SW Topeka Blvd		Topeka	KS	66629				1133 SW Topeka Blvd		Topeka	KS	66629				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsks.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1					3	0	0	www.bcbsks.com/medicare	www.MyPrime.com	www.bcbsks.com/medicare
H7076	011	0	2021	01	CareSource Advantage (HMO)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/in/plans/medicare/	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $30.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $30.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/in/plans/medicare/benefits-services/pharmacy/drug-formulary/
H7076	012	0	2021	01	CareSource Advantage (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/in/plans/medicare/	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/in/plans/medicare/benefits-services/pharmacy/drug-formulary/
H7076	013	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/in/plans/medicare/	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/in/plans/medicare/benefits-services/pharmacy/drug-formulary/
H7076	014	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/in/plans/medicare/	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/in/plans/medicare/benefits-services/pharmacy/drug-formulary/
H7076	015	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/in/plans/dsnp/	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/in/plans/dsnp/pharmacy/drug-formulary/
H7076	016	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/in/plans/dsnp/	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/in/plans/dsnp/pharmacy/drug-formulary/
H7114	001	0	2021	20	Dual (PACE)	Oklahoma County		Oklahoma County	1	3	0									721 NW 6th		Oklahoma City	OK	73102		pace@valir.com	pace@valir.com	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.valirpace.org	0	0	1			0					3	0	0		www.valir.com	www.valir.com
H7114	002	0	2021	20	Medicare Only (PACE)	Oklahoma County		Oklahoma County	1	3	0									721 NW 6th		Oklahoma City	OK	73102		pace@valir.com	pace@valir.com	3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.valirpace.org	0	0	1			0					3	0	0		www.valir.com	www.valir.com
H7115	001	0	2021	01	Memorial Hermann Advantage (HMO)	Texas Counties - Harris, Montgomery, Fort Bend		Texas Counties - Harris, Montgomery, Fort Bend	1	0	0	929 Gessner #1500		Houston	TX	77024				929 Gessner #1500		Houston	TX	77024				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	healthplan.memorialhermann.org/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare
H7115	003	0	2021	01	Memorial Hermann Advantage Plus (HMO)	Texas Counties - Harris, Montgomery, Fort Bend		Texas Counties - Harris, Montgomery, Fort Bend	1	0	0	929 Gessner #1500		Houston	TX	77024				929 Gessner #1500		Houston	TX	77024				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	healthplan.memorialhermann.org/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare
H7115	805	0	2021	01	Memorial Hermann Advantage (HMO)	Texas Counties - Harris, Montgomery, Fort Bend		Texas Counties - Harris, Montgomery, Fort Bend	1	3	1	929 Gessner #1500		Houston	TX	77024				929 Gessner #1500		Houston	TX	77024				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthplan.memorialhermann.org/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare
H7115	806	0	2021	01	Memorial Hermann Advantage (HMO)	Texas Counties - Harris, Montgomery, Fort Bend		Texas Counties - Harris, Montgomery, Fort Bend	1	3	1	929 Gessner #1500		Houston	TX	77024				929 Gessner #1500		Houston	TX	77024				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthplan.memorialhermann.org/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare
H7115	807	0	2021	01	Memorial Hermann Advantage (HMO)	Texas Counties - Harris, Montgomery, Fort Bend		Texas Counties - Harris, Montgomery, Fort Bend	1	3	1	929 Gessner #1500		Houston	TX	77024												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthplan.memorialhermann.org/medicare	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare	healthplan.memorialhermann.org/medicare
H7119	001	0	2021	01	Provider Partners Ohio Advantage Plan (HMO I-SNP)	Central, Southern, Northeastern		Central, Southern, Northeastern	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H7123	001	0	2021	01	UPMC for Life Complete Care (HMO D-SNP)	Southeastern Pennsylvania		Southeastern Pennsylvania	1	0	0	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu	2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.upmchealthplan.com/snp	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	http://www.upmchealthplan.com/snp	www.upmchealthplan.com/medicare/documents-and-forms	www.upmchealthplan.com/medicare/documents-and-forms
H7149	001	0	2021	01	Aetna Medicare Premier (HMO)	Partial State of Nebraska		Partial State of Nebraska	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7149	004	0	2021	01	Aetna Medicare Prime (HMO)	Douglas and Sarpy Counties		Douglas and Sarpy Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7149	006	0	2021	01	Aetna Medicare Assure Premier (HMO D-SNP)	Douglas, Lancaster and Sarpy counties		Douglas, Lancaster and Sarpy counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7149	801	0	2021	01	Aetna Medicare Plan (HMO)	Nebraska		Nebraska	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7149	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Nebraska		Nebraska	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7163	002	0	2021	02	Vantage BASIC (HMO-POS)	Central and South Mississippi		Central and South Mississippi	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H7163	003	0	2021	02	Vantage DUAL PLUS (HMO-POS D-SNP)	Central and South Mississippi		Central and South Mississippi	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H7163	004	0	2021	02	Vantage STANDARD (HMO-POS)	Central and South Mississippi		Central and South Mississippi	1	0	0	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H7163	801	0	2021	02	Vantage - MAPD Employer Calendar (HMO-POS)	Mississippi		Mississippi	1	3	1	130 DeSiard St	Suite 300	Monroe	LA	71201				130 DeSiard St	Suite 300	Monroe	LA	71201				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.VantageMedicare.com	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.VantageMedicare.com	www.VantageMedicare.com	www.VantageMedicare.com
H7165	001	0	2021	01	BlueCross Secure (HMO)	Greenville County		Greenville County	1	0	0	P.O. Box 100191		Columbia	SC	29223				P.O. Box 100191		Columbia	SC	29223				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $70.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $70.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H7165	002	0	2021	01	BlueCross Secure (HMO)	Richland County		Richland County	1	0	0	P.O. Box 100191		Columbia	SC	29223				P.O. Box 100191		Columbia	SC	29223				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $70.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $70.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H7165	805	0	2021	01	BlueCross MAPD Calendar Year (HMO)	Nationwide		Nationwide	1	3	1	P.O. Box 100191		Columbia	SC	29223				P.O. Box 100191		Columbia	SC	29223				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H7165	806	0	2021	01	BlueCross MAPD Non-Calendar Year (HMO)	Nationwide		Nationwide	1	3	1	P.O. Box 100191		Columbia	SC	29223				P.O. Box 100191		Columbia	SC	29223				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H7172	001	0	2021	48	Aetna Better Health of Ohio, MyCare Ohio (Medicare-Medicaid Plan)	Ohio		Ohio	1	0	0	7400 West Campus Road		New Albany	OH	43054				7400 West Campus Road		New Albany	OH	43054				9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.aetnabetterhealth.com/ohio	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.aetnabetterhealth.com/ohio	www.aetnabetterhealth.com/ohio	www.aetnabetterhealth.com/ohio
H7173	001	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Metro Atl, N. GA, Counties: CE, HS, HE, SP, TP		Metro Atl, N. GA, Counties: CE, HS, HE, SP, TP	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	allwell.pshpgeorgia.com	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/formulary
H7173	002	0	2021	01	Allwell Medicare (HMO)	CY, DA, DO, FY, FU, GW, HY, PA, RO, SP, TP		CY, DA, DO, FY, FU, GW, HY, PA, RO, SP, TP	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pshpgeorgia.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $280.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $280.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/formulary
H7173	007	0	2021	01	Allwell Medicare Premier (HMO)	Counties: DA, FU, GE, GW, ME		Counties: DA, FU, GE, GW, ME	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.pshpgeorgia.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/formulary
H7173	801	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pshpgeorgia.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/formulary
H7173	802	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pshpgeorgia.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/formulary
H7173	803	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.pshpgeorgia.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/findadoctor	allwell.pshpgeorgia.com/formulary
H7175	001	0	2021	04	WellCare Premier (PPO)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7175	002	0	2021	04	WellCare Imperial (PPO D-SNP)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7175	003	0	2021	04	WellCare Summit (PPO)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7175	004	0	2021	04	WellCare Absolute (PPO)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7175	005	0	2021	04	WellCare Patriot (PPO)	Select counties in NC		Select counties in NC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7195	001	0	2021	20	Northland PACE - Dual (PACE)	Burleigh, Morton, Stark and Ward Counties		Burleigh, Morton, Stark and Ward Counties	1	3	0									2223 East Rosser Avenue		Bismarck	ND	58501		rbosch@northlandhealth.com	rbosch@northlandhealth.com	3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.northlandpace.com	0	0	1			0					3	0	0		http://www.pharmastarpbm.com/	n/a
H7195	002	0	2021	20	Northland PACE - Medicare Only (PACE)	Burleigh, Morton, Stark and Ward Counties		Burleigh, Morton, Stark and Ward Counties	1	3	0									2223 East Rosser Avenue		Bismarck	ND	58501		rbosch@northlandhealth.com	rbosch@northlandhealth.com	3100000000200001100300000000400000000511000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.northlandpace.com	0	0	1			0					3	0	0		http://www.pharmastarpbm.com/	n/a
H7220	002	0	2021	01	IU Health Plans Medicare Select (HMO)	State of Indiana - 31 counties		State of Indiana - 31 counties	1	0	0	950 N. Meridian Street	Suite 200	Indianapolis	IN	46204												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.iuhealthplans.org	0	0	2	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0					3	0	0	www.iuhealthplans.org	www.iuhealthplans.org	www.iuhealthplans.org
H7220	004	0	2021	02	IU Health Plans Medicare Choice (HMO-POS)	State of Indiana - 25 counties		State of Indiana - 25 counties	1	0	0	950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.iuhealthplans.org	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.iuhealthplans.org	www.iuhealthplans.org	www.iuhealthplans.org
H7220	009	1	2021	01	IU Health Plans Medicare Select Plus (HMO)	Indianapolis Metro Area and Surrounding Counties		State of Indiana - 33 counties	1	0	0	950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.iuhealthplans.org	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.iuhealthplans.org	www.iuhealthplans.org	www.iuhealthplans.org
H7220	009	2	2021	01	IU Health Plans Medicare Select Plus (HMO)	Indianapolis Metro Area and Surrounding Counties		Indianapolis Metro Area	1	0	0	950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.iuhealthplans.org	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.iuhealthplans.org	www.iuhealthplans.org	www.iuhealthplans.org
H7220	009	3	2021	01	IU Health Plans Medicare Select Plus (HMO)	Indianapolis Metro Area and Surrounding Counties		Ft. Wayne Area	1	0	0	950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				950 N. Meridian Street	Suite 200	Indianapolis	IN	46204				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.iuhealthplans.org	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.iuhealthplans.org	www.iuhealthplans.org	www.iuhealthplans.org
H7245	001	0	2021	01	Premera Blue Cross Medicare Advantage (HMO)	Various Counties in Eastern and Western WA		Various Counties in Eastern and Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H7245	002	0	2021	01	Premera Blue Cross Medicare Advantage Classic (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H7245	003	0	2021	01	Premera Blue Cross Medicare Advantage Classic Plus (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H7245	005	0	2021	01	Premera Blue Cross Medicare Advantage Total Health (HMO)	Various Counties in Eastern WA		Various Counties in Eastern WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H7245	006	0	2021	01	Premera Blue Cross Medicare Advantage Core (HMO)	Various Counties in Eastern and Western WA		Various Counties in Eastern and Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H7245	008	0	2021	01	Premera Blue Cross Medicare Advantage Core Plus (HMO)	Various Counties in Eastern and Western WA		Various Counties in Eastern and Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H7262	001	0	2021	20	TRU Community Care (PACE)	Boulder and Southwest Weld Counties		Boulder and Southwest Weld Counties	1	3	0									2593 Park Lane		Lafayette	CO	80026		samanthablack@trucare.org	samanthablack@trucare.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pace.trucare.org	0	0	1			0					3	0	0		TBD	www.trucare.org
H7262	002	0	2021	20	TRU Community Care (PACE)	Boulder and Southwest Weld Counties		Boulder and Southwest Weld Counties	1	3	0									2593 Park Lane		Lafayette	CO	80026		samanthablack@trucare.org	samanthablack@trucare.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pace.trucare.org	0	0	1			0					3	0	0		TBD	www.trucare.org
H7273	001	0	2021	04	Banner Medicare Advantage Plus (PPO)	Maricopa and Pinal Counties	Banner Medicare Advantage Plus (PPO)	Maricopa and Pinal Counties	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.BannerMA.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.BannerMA.com	https://www.bannerhealth.com/	https://www.bannerhealth.com/
H7273	002	0	2021	04	Banner Medicare Advantage Plus (PPO)	Pima County	Banner Medicare Advantage Plus (PPO)	Pima County	1	0	0	2701 E. Elvira Rd.		Tucson	AZ	85756				2701 E. Elvira Rd.		Tucson	AZ	85756				4108002000208002000308002000408002000508002000608002000708002000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bannerhealth.com/services/insurance	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://www.bannerhealth.com/physician-directory	https://www.bannerhealth.com/	https://www.bannerhealth.com/
H7284	001	0	2021	04	HumanaChoice Florida H7284-001 (PPO)	Lake, Marion, Seminole and Sumter counties		Lake, Marion, Seminole and Sumter counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7284	002	0	2021	04	HumanaChoice Florida H7284-002 (PPO)	Charlotte, Collier and Lee counties		Charlotte, Collier and Lee counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7284	003	0	2021	04	HumanaChoice SNP-DE H7284-003 (PPO D-SNP)	North Florida Rural Counties		North Florida Rural Counties	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7284	006	0	2021	04	HumanaChoice Florida H7284-006 (PPO)	Daytona and Jacksonville		Daytona and Jacksonville	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7301	002	0	2021	04	Aetna Medicare Premier Advantra (PPO)	Northern/Northwestern Illinois		Northern/Northwestern Illinois	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7301	006	0	2021	04	Aetna Medicare Value Advantra (PPO)	Northern/Northwestern Illinois		Northern/Northwestern Illinois	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7301	007	0	2021	04	Aetna Medicare Value Advantra (PPO)	Illinois		Illinois	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7301	009	0	2021	04	Aetna Medicare Premier Advantra (PPO)	Illinois		Illinois	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7301	801	0	2021	04	Aetna Medicare Plan w/Rx (PPO)	Illinois		Illinois	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7301	803	0	2021	04	Aetna Medicare Plan (PPO)	Illinois		Illinois	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H7322	001	0	2021	01	Montefiore + Oscar Easy Care (HMO)	Bronx County		Bronx County	1	0	0	PO Box 62045		Phoenix	AZ	85082				PO Box 62045		Phoenix	AZ	85082				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hioscar.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.hioscar.com/search	www.hioscar.com/search	www.hioscar.com/search
H7322	002	0	2021	01	Oscar Easy Care (HMO)	Orange, Rockland and Westchester Counties		Orange, Rockland and Westchester Counties	1	0	0	PO Box 62045		Phoenix	AZ	85082				PO Box 62045		Phoenix	AZ	85082				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hioscar.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.hioscar.com/search	www.hioscar.com/search	www.hioscar.com/search
H7322	003	0	2021	01	Montefiore + Oscar Extra Benefits (HMO)	Bronx County		Bronx County	1	0	0	PO Box 62045		Phoenix	AZ	85082				PO Box 62045		Phoenix	AZ	85082				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.hioscar.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.hioscar.com/search	www.hioscar.com/search	www.hioscar.com/search
H7323	001	0	2021	04	WellCare Prime (PPO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7323	002	0	2021	04	WellCare Premier (PPO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7323	003	0	2021	04	WellCare Premier (PPO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7323	004	0	2021	04	WellCare Prime (PPO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7323	005	0	2021	04	WellCare Imperial (PPO D-SNP)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7323	006	0	2021	04	WellCare Rx Plus (PPO)	Select counties in TX		Select counties in TX	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7326	001	0	2021	04	WellCare Premier (PPO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7326	002	0	2021	04	WellCare Prime (PPO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7326	003	0	2021	04	WellCare Absolute (PPO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $90.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $90.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7326	004	0	2021	04	WellCare Flex Complete (PPO)	Select counties in SC		Select counties in SC	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7330	001	0	2021	01	Zing Choice IL (HMO)	Cook County	Zing Choice IL (HMO)	Cook County	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H7330	002	0	2021	02	Zing Open Access IL (HMO-POS)	Cook County	Zing Open Access IL (HMO-POS)	Cook County	1	0	0	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H7330	801	0	2021	01	Zing EGWP CY (HMO)	Cook County	Zing EGWP CY (HMO)	Cook County	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H7330	802	0	2021	01	Zing EGWP NCY (HMO)	Cook County	Zing EGWP NCY (HMO)	Cook County	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com	303 West Madison Street	Suite 800	Chicago	IL	60606		rx@myzinghealth.com	rx@myzinghealth.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H7330	803	0	2021	01	Zing EGWP MA Only CY (HMO)	Cook County	Zing EGWP MA Only CY (HMO)	Cook County	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H7330	804	0	2021	01	Zing EGWP MA Only NCY (HMO)	Cook County	Zing EGWP MA Only NCY (HMO)	Cook County	1	3	1	303 West Madison Street	Suite 800	Chicago	IL	60606		member.services@myzinghealth.com	member.services@myzinghealth.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	myzinghealth.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	myzinghealth.com	myzinghealth.com	myzinghealth.com
H7399	001	0	2021	01	Ascension Complete AMITA Health Reward (HMO)	Cook, DuPage, Kane and Will Counties		Cook, DuPage, Kane and Will Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $430.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $430.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/il-findadoctor	ascensioncomplete.com/il-findadoctor	ascensioncomplete.com/il-formulary
H7399	002	0	2021	01	Ascension Complete AMITA Health Secure (HMO)	Cook, DuPage, Kane and Will Counties		Cook, DuPage, Kane and Will Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/il-findadoctor	ascensioncomplete.com/il-findadoctor	ascensioncomplete.com/il-formulary
H7404	001	0	2021	04	AARP Medicare Advantage Headwaters (PPO)	Select Counties in Twin Cities Area		Select Counties in Twin Cities Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	002	0	2021	04	AARP Medicare Advantage Lakeshore (PPO)	Select Counties in Twin Cities Area		Select Counties in Twin Cities Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	004	0	2021	04	AARP Medicare Advantage Premier (PPO)	Select Counties in Minnesota and North Dakota		Select Counties in Minnesota and North Dakota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H7404	005	0	2021	04	AARP Medicare Advantage Headwaters (PPO)	Select Counties in Minnesota and North Dakota		Select Counties in Minnesota and North Dakota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	006	0	2021	04	AARP Medicare Advantage Lakeshore (PPO)	Select Counties in Minnesota and North Dakota		Select Counties in Minnesota and North Dakota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	011	0	2021	04	AARP Medicare Advantage Headwaters (PPO)	Select Counties in MN		Select Counties in MN	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	012	0	2021	04	AARP Medicare Advantage Lakeshore (PPO)	Select Counties in MN		Select Counties in MN	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	014	0	2021	04	AARP Medicare Advantage Riverbank (PPO)	Select Counties in Twin Cities Area		Select Counties in Twin Cities Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	015	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties in Minnesota		Select Counties in Minnesota	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H7404	018	0	2021	04	AARP Medicare Advantage Choice (PPO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	019	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	020	0	2021	04	AARP Medicare Advantage Walgreens Plan 2 (PPO)	Clark and Nye counties		Clark and Nye counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7404	021	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select counties in Northern Utah		Select counties in Northern Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7409	001	0	2021	01	Bright Advantage (HMO)	Spartanburg Area		Spartanburg Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H7419	001	0	2021	48	Tufts Health Unify (Medicare-Medicaid Plan)	Middlesex, Worcester and Suffolk counties	Tufts Health Unify (Medicare-Medicaid Plan)	Middlesex, Worcester and Suffolk counties	1	0	0	705 Mount Auburn Street		Watertown	MA	02472				705 Mount Auburn Street		Watertown	MA	02472				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.ChooseUnify.org	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.TuftsHealthUnify.org	www.TuftsHealthUnify.org	www.TuftsHealthUnify.org
H7445	004	0	2021	01	UnitedHealthcare Medicare Advantage (HMO)	Carroll county		Carroll county	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H7445	005	0	2021	01	AARP Medicare Advantage (HMO)	Kent, New Castle, and Sussex counties		Kent, New Castle, and Sussex counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7445	006	0	2021	01	AARP Medicare Advantage Patriot (HMO)	Kent, New Castle, and Sussex counties		Kent, New Castle, and Sussex counties	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H7464	001	0	2021	01	UnitedHealthcare Dual Complete (HMO D-SNP)	Select Counties in VA		Select Counties in VA	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H7464	005	0	2021	01	UnitedHealthcare Dual Complete ONE (HMO D-SNP)	VA FIDE Aligned non Complex		VA FIDE Aligned non Complex	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H7469	001	0	2021	20	PACE Partners of Northeast Florida (PACE)	Duval, Clay, Nassau and St. Johns Counties		Duval, Clay, Nassau and St. Johns Counties	1	3	0									5450 Ramona Boulevard		Jacksonville	FL	32205		mkiefert@pacenefl.com	mkiefert@thepaceplace.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	thepaceplace.org	0	0	1			0					3	0	0	N/A	@trhc.com	N/A
H7469	002	0	2021	20	PACE Partners of Northeast Florida MO (PACE)	Medicare Only		Medicare Only	1	3	0									5450 Ramona Boulevard		Jacksonville	FL	32205		mkiefert@pacenefl.com	mkiefert@pacenefl.com	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	@thepaceplace.org	0	0	1			0					3	0	0	N/A	@trhc.com	N/A
H7501	001	0	2021	20	CalOptima PACE (PACE)	Orange County, California		Orange County, California	1	3	0									13300 Garden Grove Blvd.		Garden Grove	CA	92843				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.caloptima.org/PACE	0	0	1			0					3	0	0		www.caloptima.org/home/providers/pharmacy.aspx	www.caloptima.org
H7501	002	0	2021	20	CalOptima PACE (PACE)	Orange County, California		Orange County, California	1	3	0									13300 Garden Grove Blvd.		Garden Grove	CA	92843				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.caloptima.org/PACE	0	0	1			0					3	0	0		www.caloptima.org/home/providers/pharmacy.aspx	www.caloptima.org
H7511	001	0	2021	01	Great Plains Medicare Advantage (HMO I-SNP)	Nebraska (partial)		Nebraska (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.greatplainsmedicareadvantage.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com
H7511	002	0	2021	01	Great Plains Medicare Advantage Gold (HMO I-SNP)	Nebraska (partial)		Nebraska (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.greatplainsmedicareadvantage.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com
H7518	001	0	2021	04	WellCare Premier (PPO)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7518	002	0	2021	04	WellCare Patriot (PPO)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7518	003	0	2021	04	WellCare Imperial (PPO D-SNP)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H7522	801	0	2021	04	MMM Advantage Group $0 Calendar (PPO)	Puerto Rico	MMM Advantage Group $0 Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H7522	802	0	2021	04	MMM Advantage Group $25 Calendar (PPO)	Puerto Rico	MMM Advantage Group $25 Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmm-pr.com
H7522	804	0	2021	04	MMM Advantage Group $50 Calendar (PPO)	Puerto Rico	MMM Advantage Group $50 Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	805	0	2021	04	MMM Advantage Group $100 Calendar (PPO)	Puerto Rico	MMM Advantage Group $100 Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	806	0	2021	04	MMM Advantage Group $0 Non-Calendar (PPO)	Puerto Rico	MMM Advantage Group $0 Non-Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	807	0	2021	04	MMM Advantage Group $25 Non-Calendar (PPO)	Puerto Rico	MMM Advantage Group $25 Non-Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	808	0	2021	04	MMM Advantage Group $50 Non-Calendar (PPO)	Puerto Rico	MMM Advantage Group $50 Non-Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	809	0	2021	04	MMM Advantage Group $100 Non-Calendar (PPO)	Puerto Rico	MMM Advantage Group $100 Non-Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	810	0	2021	04	MMM Advantage Group $144.60 Calendar (PPO)	Puerto Rico	MMM Advantage Group $144.60 Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7522	811	0	2021	04	MMM Advantage Group $144.60 Non-Calendar (PPO)	Puerto Rico	MMM Advantage Group $144.60 Non-Calendar (PPO)	Puerto Rico	1	3	1	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	350 Chardon Avenue	Suite 500 Torre Chardon	San Juan	PR	00918		manuel.sanchez@mmmhc.com	manuel.sanchez@mmmhc.com	1108002000208002000308002000408002000508002000608002000708002000	1108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mmmpr.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	1					3	0	0	www.mmmpr.com	www.mmm-pr.com	www.mmmpr.com
H7557	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	MI service areas		MI service areas	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H7559	001	0	2021	01	Magellan Complete Care of Virginia, LLC (HMO D-SNP)	Virginia		Virginia	1	0	0	3829 Gaskins Road		Richmond	VA	23233				3829 Gaskins Road		Richmond	VA	23233				9000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	mccofva.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	mccofva.com	mccofva.com
H7594	001	0	2021	01	Brandman Health Plan (Arise) (HMO C-SNP)	Los Angeles County		Los Angeles County	1	0	0	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.brandmanhealthplan.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.brandmanhealthplan.com	www.Brandmanhealth.com	www.Brandmanhealth.com
H7594	002	0	2021	01	Brandman Health Plan (Arise-D) (HMO C-SNP)	Los Angeles County		Los Angeles County	1	0	0	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.brandmanhealthplan.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.brandmanhealthplan.com	www.Brandmanhealth.com	www.Brandmanhealth.com
H7594	003	0	2021	01	Brandman Health Plan (Aspire) (HMO C-SNP)	Los Angeles County		Los Angeles County	1	0	0	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.brandmanhealthplan.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.brandmanhealthplan.com	www.Brandmanhealth.com	www.Brandmanhealth.com
H7594	004	0	2021	01	Brandman Health Plan (Aspire-D) (HMO C-SNP)	Los Angeles County		Los Angeles County	1	0	0	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	7150 Tampa Avenue		Reseda	CA	91335		memberservices@brandmanhealthplan.com	memberservices@brandmanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.brandmanhealthplan.com	1	4	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.brandmanhealthplan.com	www.Brandmanhealth.com	www.Brandmanhealth.com
H7598	001	0	2021	01	Cooperative Advantage Premium (HMO I-SNP)	Wisconsin		Wisconsin	1	0	0	2503 N Hillcrest Parkway		Altoona	WI	54720				2503 N Hillcrest Parkway		Altoona	WI	54720				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	0	3	Approved by Medicare	Aprobado por Medicare	0	www.group-health.com	1	1	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://group-health.com/members/find-a-doctor	www.group-health.com	www.group-health.com
H7598	002	0	2021	01	Cooperative Advantage (HMO I-SNP)	Wisconsin		Wisconsin	1	0	0	2503 N Hillcrest Parkway		Altoona	WI	54720				2503 N Hillcrest Parkway		Altoona	WI	54720				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.group-health.com	1	1	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	https://group-health.com/members/find-a-doctor	www.group-health.com	www.group-health.com
H7607	002	1	2021	01	Clever Care Longevity Medicare Advantage (HMO)	Los Angeles, Orange, and San Diego Counties		Los Angeles County	1	0	0	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		Sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clevercarehealthplan.com/plans	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	www.clevercarehealthplan.com/provider	www.clevercarehealthplan.com/pharmacy	www.clevercarehealthplan.com/formulary
H7607	002	2	2021	01	Clever Care Longevity Medicare Advantage (HMO)	Los Angeles, Orange, and San Diego Counties		Orange County	1	0	0	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		Sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clevercarehealthplan.com/plans	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	www.clevercarehealthplan.com/provider	www.clevercarehealthplan.com/pharmacy	www.clevercarehealthplan.com/formulary
H7607	002	3	2021	01	Clever Care Longevity Medicare Advantage (HMO)	Los Angeles, Orange, and San Diego Counties		San Diego County	1	0	0	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		Sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clevercarehealthplan.com/plans	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0					3	0	0	www.clevercarehealthplan.com/provider	www.clevercarehealthplan.com/pharmacy	www.clevercarehealthplan.com/formulary
H7607	003	1	2021	01	Clever Care Balance Medicare Advantage (HMO)	Los Angeles, Orange, and San Diego Counties		Los Angeles County	1	0	0	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clevercarehealthplan.com/plans	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clevercarehealthplan.com/provider	www.clevercarehealthplan.com/pharmacy	www.clevercarehealthplan/formulary
H7607	003	2	2021	01	Clever Care Balance Medicare Advantage (HMO)	Los Angeles, Orange, and San Diego Counties		Orange County	1	0	0	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clevercarehealthplan.com/plans	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clevercarehealthplan.com/provider	www.clevercarehealthplan.com/pharmacy	www.clevercarehealthplan/formulary
H7607	003	3	2021	01	Clever Care Balance Medicare Advantage (HMO)	Los Angeles, Orange, and San Diego Counties		San Diego County	1	0	0	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	8990 Westminster Blvd.	3rd Floor	Westminster	CA	92683		sales@clevercarehealthplan.com	customerservice@clevercarehealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clevercarehealthplan.com/plans	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $435.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $435.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.clevercarehealthplan.com/provider	www.clevercarehealthplan.com/pharmacy	www.clevercarehealthplan/formulary
H7617	001	0	2021	04	HumanaChoice H7617-001 (PPO)	Greenville County		Greenville County	1	0	0	500 West Main St.		Louisville	KY	40202				500 West Main St.		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7619	001	0	2021	20	AtlantiCare LIFE Connection (PACE)	Counties: Atlantic, Cape May		Counties: Atlantic, Cape May	1	3	0									1401 Atlantic Ave		Atlantic City	NJ	08401		Alex.Casiano@atlanticare.org	michael.dibiase@atlanticare.org	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.atlanticare.org/services/life-connection/	0	0	1			0					3	0	0		NA	NA
H7619	002	0	2021	20	AtlantiCare LIFE Connection (PACE)	Counties: Atlantic, Cape May		Counties: Atlantic, Cape May	1	3	0									1401 Atlantic Ave		Atlantic City	NJ	08401		Alex.Casiano@atlanticare.org	Alex.Casiano@atlanticare.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.atlanticare.org/services/life-connection/	0	0	1			0					3	0	0		NA	NA
H7621	001	0	2021	01	Humana Community (HMO)	Select Counties in Kansas City Metro area		Select Counties in Kansas City Metro area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7621	002	0	2021	01	Humana Community (HMO)	Riverside County		Riverside County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7621	003	0	2021	01	Humana Community (HMO)	San Joaquin County		San Joaquin County	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H7646	001	0	2021	02	Sparrow Advantage (HMO-POS)	Greater Lansing Area		Greater Lansing Area	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.sparrowadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmichigan.com/myphp	www.sparrowadvantage.com	www.sparrowadvantage.com
H7646	002	0	2021	02	Covenant Advantage (HMO-POS)	Bay, Saginaw, Tuscola counties		Bay, Saginaw, Tuscola counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.covenantadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmichigan.com/myphp	www.covenantadvantage.com	www.covenantadvantage.com
H7646	003	0	2021	02	PHP Advantage (HMO-POS)	Calhoun and Kalamazoo counties		Calhoun and Kalamazoo counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.phpadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmichigan.com/myphp	www.phpadvantage.com	www.phpadvantage.com
H7646	004	0	2021	02	Sparrow Advantage Plus (HMO-POS)	Greater Lansing Area		Greater Lansing Area	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.sparrowadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmichigan.com/myphp	www.sparrowadvantage.com	www.sparrowadvantage.com
H7646	005	0	2021	02	Covenant Advantage Plus (HMO-POS)	Bay, Saginaw, Tuscola counties		Bay, Saginaw, Tuscola counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.covenantadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmichigan.com/myphp	www.covenantadvantage.com	www.covenantadvantage.com
H7646	006	0	2021	02	PHP Advantage Plus (HMO-POS)	Calhoun and Kalamazoo counties		Calhoun and Kalamazoo counties	1	0	0	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.phpadvantage.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmichigan.com/myphp	www.phpadvantage.com	www.phpadvantage.com
H7646	801	0	2021	02	EGWP MAPD Calendar year (HMO-POS)	Certain Counties in Michigan		Certain Counties in Michigan	1	3	1	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000000000000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phpmedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmedicare.com	www.phpmedicare.com	www.phpmedicare.com
H7646	802	0	2021	02	EGWP MAPD Non-Calendar year (HMO-POS)	Certain Counties in Michigan		Certain Counties in Michigan	1	3	1	PO Box 12487		St. Louis	MO	63132				PO Box 12487		St. Louis	MO	63132				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.phpmedicare.com	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.phpmedicare.com	www.phpmedicare.com	www.phpmedicare.com
H7660	001	0	2021	20	VieCare Beaver, LLC dba LIFE Beaver and Lawrence C (PACE)	Beaver and Lawrence Counties		Beaver and Lawrence Counties	1	3	0									131 Pleasant Drive, Suite 1		Aliquippa	PA	15001		dave.hamm@lutheranseniorlife.org		2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.lutheranseniorlife.org	0	0	1			0					3	0	0		www.lutheranseniorlife.org	www.lutheranseniorlife.org
H7660	002	0	2021	20	VieCare Beaver, LLC dba LIFE Beaver and Lawrence C (PACE)	Beaver and Lawrence Counties		Beaver and Lawrence Counties	1	3	0									131 Pleasant Drive, Suite 1		Aliquippa	PA	15001				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.LutheranSeniorLife.org	0	0	1			0					3	0	0		www.lutheranseniorlife.org	www.lutheranseniorlife.org
H7678	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in Texas		Select Counties in Texas	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H7680	001	0	2021	01	Prominence Plus (HMO)	Potter,Gray,Moore,DS,Cooke,Fannin,Grayson,Randall		Potter,Gray,Moore,DS,Cooke,Fannin,Grayson,Randall	1	0	0	1510 Meadow Wood Lane		Reno	NV	89502				1510 Meadow Wood Lane		Reno	NV	89502				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H7680	002	0	2021	01	Prominence Plus (HMO)	Hildago,Starr and Brooks, Webb		Hildago,Starr and Brooks, Webb	1	0	0	1510 Meadow Wood Lane		Reno	NV	89502				1510 Meadow Wood Lane		Reno	NV	89502				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H7680	801	0	2021	01	Prominence Health Plan (HMO)	National		National	1	3	1	1510 Meadow Wood Lane		Reno	NV	89502												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H7680	804	0	2021	01	Prominence Health Plan (HMO)	National		National	1	3	1	1510 Meadow Wood Lane		Reno	NV	89502												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prominencemedicare.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.prominencemedicare.com	www.prominencemedicare.com	www.prominencemedicare.com
H7728	002	0	2021	04	Anthem MediBlue Access (PPO)	State of New Hampshire		State of New Hampshire	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	004	1	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	P.O. Box 659404		San Antonio	TX	78265		medicaresales@anthem.com		P.O. Box 659404		San Antonio	TX	78265			medicaresales@anthem.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	004	2	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	P.O. Box 659404		San Antonio	TX	78265		medicaresales@anthem.com		P.O. Box 659404		San Antonio	TX	78265			medicaresales@anthem.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	005	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	006	0	2021	04	Anthem MediBlue Access Basic (PPO)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	008	0	2021	04	Anthem MediBlue Access Core (PPO)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	P.O. Box 659404	CN14B-818	San Antonio	TX	78265		medicaresales@anthem.com										2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	009	0	2021	04	Anthem MediBlue Access Plus (PPO)	Select Counties in Kentucky		Select Counties in Kentucky	1	0	0	P.O. Box 659404	CN14B-818	San Antonio	TX	78265		medicaresales@anthem.com		P.O. Box 659404		San Antonio	TX	78265			medicaresales@anthem.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H7728	801	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	802	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	803	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	804	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	805	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	806	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	807	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	808	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	809	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	810	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	811	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7728	812	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H7779	001	0	2021	01	American Health Advantage of Tennessee (HMO I-SNP)	Tennessee		Tennessee	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	tn.AmHealthPlans.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	tn.AmHealthPlans.com	tn.AmHealthPlans.com	tn.AmHealthPlans.com
H7787	001	0	2021	04	Cigna Preferred Medicare (PPO)	North Texas	Cigna Preferred Medicare (PPO)	North Texas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7787	002	0	2021	04	Cigna Fundamental Medicare (PPO)	North Texas	Cigna Fundamental Medicare (PPO)	North Texas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7833	001	0	2021	48	UnitedHealthcare Connected (Medicare-Medicaid Plan)	Harris County	UnitedHealthcare Connected (Medicare-Medicaid Plan)	Harris County	1	0	0	PO Box 29675		Hot Springs	AR	71903				PO Box 29675		Hot Springs	AR	71903				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.UHCCommunityplan.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.UHCCommunityplan.com	www.optumrx.com	www.UHCCommunityplan.com
H7844	001	0	2021	48	Molina Dual Options (Medicare-Medicaid Plan)	Wayne and Macomb Counties		Wayne and Macomb Counties	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H7849	001	0	2021	04	Cigna True Choice Medicare (PPO)	Denver and Boulder Area	Cigna True Choice Medicare (PPO)	Denver and Boulder Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	002	0	2021	04	Cigna True Choice Medicare (PPO)	Chicago Area	Cigna True Choice Medicare (PPO)	Chicago Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	003	0	2021	04	Cigna True Choice Medicare (PPO)	Georgia	Cigna True Choice Medicare (PPO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	006	0	2021	04	Cigna True Choice Medicare (PPO)	Philadelphia Area	Cigna True Choice Medicare (PPO)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	007	0	2021	04	Cigna True Choice Plus Medicare (PPO)	Philadelphia Area	Cigna True Choice Plus Medicare (PPO)	Philadelphia Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	008	0	2021	04	Cigna True Choice Medicare (PPO)	Washington DC and Delaware	Cigna True Choice Medicare (PPO)	Washington DC and Delaware	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	009	0	2021	04	Cigna True Choice Plus Medicare (PPO)	Washington DC and Delaware	Cigna True Choice Plus Medicare (PPO)	Washington DC and Delaware	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	010	0	2021	04	Cigna True Choice Medicare (PPO)	Middle Tennessee	Cigna True Choice Medicare (PPO)	Middle Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	011	0	2021	04	Cigna True Choice Medicare (PPO)	North Carolina	Cigna True Choice Medicare (PPO)	North Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	012	0	2021	04	Cigna True Choice Medicare (PPO)	Alabama	Cigna True Choice Medicare (PPO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	013	0	2021	04	Cigna True Choice Medicare (PPO)	Alabama	Cigna True Choice Medicare (PPO)	Alabama	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	014	0	2021	04	Cigna True Choice Medicare (PPO)	Treasure Coast	Cigna True Choice Medicare (PPO)	Treasure Coast	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	015	0	2021	04	Cigna True Choice Medicare (PPO)	Ohio	Cigna True Choice Medicare (PPO)	Ohio	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	016	0	2021	04	Cigna True Choice Medicare (PPO)	Southern Mississippi	Cigna True Choice Medicare (PPO)	Southern Mississippi	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	017	0	2021	04	Cigna True Choice Medicare (PPO)	Orlando Area	Cigna True Choice Medicare (PPO)	Orlando Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	018	0	2021	04	Cigna True Choice Medicare (PPO)	South Carolina	Cigna True Choice Medicare (PPO)	South Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	019	0	2021	04	Cigna True Choice Medicare (PPO)	North Carolina	Cigna True Choice Medicare (PPO)	North Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	020	0	2021	04	Cigna True Choice Medicare (PPO)	Georgia	Cigna True Choice Medicare (PPO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	021	0	2021	04	Cigna True Choice Medicare (PPO)	Georgia	Cigna True Choice Medicare (PPO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	022	0	2021	04	Cigna True Choice Medicare (PPO)	Georgia	Cigna True Choice Medicare (PPO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	023	0	2021	04	Cigna True Choice Plus Medicare (PPO)	Georgia	Cigna True Choice Plus Medicare (PPO)	Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $95.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $95.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	024	0	2021	04	Cigna True Choice Medicare (PPO)	Kansas City Area	Cigna True Choice Medicare (PPO)	Kansas City Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	026	0	2021	04	Cigna True Choice Medicare (PPO)	Fort Collins Area	Cigna True Choice Medicare (PPO)	Fort Collins Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	027	0	2021	04	Cigna True Choice Medicare (PPO)	Colorado Springs Area	Cigna True Choice Medicare (PPO)	Colorado Springs Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	028	0	2021	04	Cigna True Choice Medicare (PPO)	Albuquerque Area	Cigna True Choice Medicare (PPO)	Albuquerque Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	029	0	2021	04	Cigna True Choice Medicare (PPO)	Salt Lake City Area	Cigna True Choice Medicare (PPO)	Salt Lake City Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	030	0	2021	04	Cigna True Choice Plus Medicare (PPO)	Central New Jersey	Cigna True Choice Plus Medicare (PPO)	Central New Jersey	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	031	0	2021	04	Cigna True Choice Medicare (PPO)	Central Pennsylvania	Cigna True Choice Medicare (PPO)	Central Pennsylvania	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	032	0	2021	04	Cigna True Choice Plus Medicare (PPO)	Central Pennsylvania	Cigna True Choice Plus Medicare (PPO)	Central Pennsylvania	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	033	0	2021	04	Cigna True Choice Plus Medicare (PPO)	Southern New Jersey	Cigna True Choice Plus Medicare (PPO)	Southern New Jersey	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	034	0	2021	04	Cigna True Choice Medicare (PPO)	Tri Cities	Cigna True Choice Medicare (PPO)	Tri Cities	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	035	0	2021	04	Cigna True Choice Medicare (PPO)	Northwest Georgia	Cigna True Choice Medicare (PPO)	Northwest Georgia	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	036	0	2021	04	Cigna True Choice Medicare (PPO)	Chattanooga Area	Cigna True Choice Medicare (PPO)	Chattanooga Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	037	0	2021	04	Cigna True Choice Medicare (PPO)	West Tennessee	Cigna True Choice Medicare (PPO)	West Tennessee	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	038	0	2021	04	Cigna True Choice Medicare (PPO)	Houston	Cigna True Choice Medicare (PPO)	Houston	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	039	0	2021	04	Cigna True Choice Medicare (PPO)	Valley	Cigna True Choice Medicare (PPO)	Valley	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	040	0	2021	04	Cigna True Choice Medicare (PPO)	North Texas	Cigna True Choice Medicare (PPO)	North Texas	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	041	0	2021	04	Cigna True Choice Medicare (PPO)	El Paso	Cigna True Choice Medicare (PPO)	El Paso	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	042	0	2021	04	Cigna True Choice Medicare (PPO)	Oklahoma City Area	Cigna True Choice Medicare (PPO)	Oklahoma City Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	043	0	2021	04	Cigna True Choice Medicare (PPO)	Knoxville Area	Cigna True Choice Medicare (PPO)	Knoxville Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	801	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide TN	Cigna True Choice Medicare (PPO)	Statewide TN	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	802	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide TN	Cigna True Choice Core Medicare (PPO)	Statewide TN	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	803	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide DC, DE, MD, VA	Cigna True Choice Medicare (PPO)	Statewide DC, DE, MD, VA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	804	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide DC, DE, MD, VA	Cigna True Choice Core Medicare (PPO)	Statewide DC, DE, MD, VA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	805	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide NJ, OH & PA	Cigna True Choice Medicare (PPO)	Statewide NJ, OH & PA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	806	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide NJ, OH & PA	Cigna True Choice Core Medicare (PPO)	Statewide NJ, OH & PA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	807	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide NC & SC	Cigna True Choice Medicare (PPO)	Statewide NC & SC	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	808	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide NC & SC	Cigna True Choice Core Medicare (PPO)	Statewide NC & SC	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	809	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide IL	Cigna True Choice Medicare (PPO)	Statewide IL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	810	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide IL	Cigna True Choice Core Medicare (PPO)	Statewide IL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	811	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide CO, NM & UT	Cigna True Choice Medicare (PPO)	Statewide CO, NM & UT	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	812	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide CO, NM & UT	Cigna True Choice Core Medicare (PPO)	Statewide CO, NM & UT	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	813	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide GA	Cigna True Choice Medicare (PPO)	Statewide GA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	814	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide GA	Cigna True Choice Core Medicare (PPO)	Statewide GA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	815	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide AL	Cigna True Choice Medicare (PPO)	Statewide AL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	816	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide AL	Cigna True Choice Core Medicare (PPO)	Statewide AL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	817	0	2021	04	Cigna True Choice Medicare (PPO)	Nationwide	Cigna True Choice Medicare (PPO)	Nationwide	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	818	0	2021	04	Cigna True Choice Core Medicare (PPO)	Nationwide	Cigna True Choice Core Medicare (PPO)	Nationwide	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignahealthspring.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignahealthspring.com
H7849	819	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide - FL	Cigna True Choice Medicare (PPO)	Statewide - FL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	820	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide - FL	Cigna True Choice Core Medicare (PPO)	Statewide - FL	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	821	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide OK & TX	Cigna True Choice Medicare (PPO)	Statewide OK & TX	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	822	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide OK & TX	Cigna True Choice Core Medicare (PPO)	Statewide OK & TX	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	823	0	2021	04	Cigna True Choice Medicare (PPO)	Statewide KS & MO	Cigna True Choice Medicare (PPO)	Statewide KS & MO	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7849	824	0	2021	04	Cigna True Choice Core Medicare (PPO)	Statewide KS & MO	Cigna True Choice Core Medicare (PPO)	Statewide KS & MO	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H7853	001	0	2021	01	Bright Advantage (HMO)	Greater Denver Area		Greater Denver Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H7853	002	0	2021	01	Bright Advantage Plus (HMO)	Greater Denver Area		Greater Denver Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H7853	005	0	2021	01	Bright Advantage Assist (HMO)	Greater Denver Area		Greater Denver Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H7853	007	0	2021	01	Bright Advantage (HMO)	Omaha Area		Omaha Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H7853	008	0	2021	01	Bright Advantage Plus (HMO)	Omaha Area		Omaha Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H7855	001	0	2021	20	Brandman Centers for Senior Care-Dual (PACE)	Brandman Centers for Senior Care-Dual		Brandman Centers for Senior Care-Dual	1	3	0									7150 Tampa Avenue		Reseda	CA	91335		Brandmanseniorcare@jha.org	brandmanseniorcare@jha.org	5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.brandmanseniorcare.org	0	0	1			0					3	0	0		www.carekinesis.com	Notapplicable
H7855	002	0	2021	20	Brandman Centers for Senior Care-Medicare Only (PACE)	Brandman Centers for Senior Care-Medicare Only		Brandman Centers for Senior Care-Medicare Only	1	3	0									7150 Tampa Avenue		Reseda	CA	91335		Brandmanseniorcare@jha.org	Brandmanseniorcare@jha.org	5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.brandmanseniorcare.org	0	0	1			0					3	0	0		www.carekinesis.com	Notapplicable
H7885	001	0	2021	48	CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan)	San Mateo County		San Mateo County	1	0	0	801 Gateway Blvd, Ste 100		South San Francisco	CA	94080		Sales@hpsm.org	CareAdvantageUnit@hpsm.org	801 Gateway Blvd, Ste 100		South San Francisco	CA	94080		Sales@hpsm.org	CareAdvantageUnit@hpsm.org	5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.hpsm.org	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	https://www.hpsm.org/provider	https://www.hpsm.org/provider	https://www.hpsm.org/member/view-my-medication-benefits
H7890	001	0	2021	48	Santa Clara Family Health Plan (Medicare-Medicaid Plan)	Santa Clara County		Santa Clara County	1	0	0	P.O. Box 18880		San Jose	CA	95158		CallCenterManagement@scfhp.com	CallCenterManagement@scfhp.com	P.O. Box 18880		San Jose	CA	95158		CallCenterManagement@scfhp.com	CallCenterManagement@scfhp.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.scfhp.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.scfhp.com/healthcareplans/calmediconnect	www.scfhp.com/healthcareplans/calmediconnect	www.scfhp.com
H7917	009	0	2021	04	BlueAdvantage Diamond (PPO)	Middle and West Tennessee		Middle and West Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	010	0	2021	04	BlueAdvantage Diamond (PPO)	Southeast Tennessee		Southeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	011	0	2021	04	BlueAdvantage Diamond (PPO)	Northeast Tennessee		Northeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	012	0	2021	04	BlueAdvantage Ruby (PPO)	West Tennessee		West Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	013	0	2021	04	BlueAdvantage Ruby (PPO)	Middle Tennessee		Middle Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	014	0	2021	04	BlueAdvantage Ruby (PPO)	Southeast Tennessee		Southeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	015	0	2021	04	BlueAdvantage Ruby (PPO)	Northeast Tennessee		Northeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	030	0	2021	04	BlueAdvantage Sapphire (PPO)	Southeast Tennessee		Southeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	031	0	2021	04	BlueAdvantage Sapphire (PPO)	Northeast Tennessee		Northeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	032	0	2021	04	BlueAdvantage Garnet (PPO)	Middle Tennessee		Middle Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	033	0	2021	04	BlueAdvantage Garnet (PPO)	West Tennessee		West Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	034	0	2021	04	BlueAdvantage Emerald (PPO)	West Tennessee		West Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	035	0	2021	04	BlueAdvantage Emerald (PPO)	Middle Tennessee		Middle Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	036	0	2021	04	BlueAdvantage Emerald (PPO)	Southeast Tennessee		Southeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	037	0	2021	04	BlueAdvantage Emerald (PPO)	Northeast Tennessee		Northeast Tennessee	1	0	0	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	801	0	2021	04	BlueAdvantage Plus (PPO)	22 County Region		22 County Region	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	802	0	2021	04	BlueAdvantage Plus (PPO)	22 County Region		22 County Region	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402				1 Cameron Hill Circle		Chattanooga	TN	37402				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7917	803	0	2021	04	BlueAdvantage Plus (PPO)	22 County Region		22 County Region	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	bcbstmedicare.com	bcbstmedicare.com	bcbstmedicare.com
H7925	001	0	2021	01	Ascension Complete St Vincent Reward (HMO)	Central, Southeast and Southwest Indiana Counties		Central, Southeast and Southwest Indiana Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $390.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $390.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/in-findadoctor	ascensioncomplete.com/in-findadoctor	ascensioncomplete.com/in-formulary
H7925	002	0	2021	01	Ascension Complete St Vincent Secure (HMO)	Central, Southeast and Southwest Indiana Counties		Central, Southeast and Southwest Indiana Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/in-findadoctor	ascensioncomplete.com/in-findadoctor	ascensioncomplete.com/in-formulary
H7971	003	0	2021	04	Horizon Medicare Blue Access (PPO)	South Jersey		South Jersey	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com/Medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	http://directory.horizonblue.com	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H7971	801	0	2021	04	Horizon Medicare Blue Group (PPO)	National		National	1	3	1	3 Penn Plaza East, PP-12F		Newark	NJ	07105												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	http://directory.horizonblue.com/	www.horizonblue.com/ma-pharmacy-search	medicare.horizonblue.com/medicare-advantage-health-insurance-new-jersey-formulary-drug-search
H7971	802	0	2021	04	Horizon Medicare Blue Group w/Rx (PPO)	National		National	1	3	1	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP- 12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	http://directory.horizonblue.com/	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPPOG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPPOG/en/find-medicine.html
H7971	807	0	2021	04	Horizon Medicare Blue Group w/Rx Ideal (PPO)	National		National	1	3	1	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP- 12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	http://directory.horizonblue.com/	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPPOG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPPOG/en/find-medicine.html
H7971	808	0	2021	04	Horizon Medicare Blue Group w/Rx Complete (PPO)	National		National	1	3	1	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP- 12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	http://directory.horizonblue.com/	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPPOG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPPOG/en/find-medicine.html
H7993	001	0	2021	01	Devoted Health Core Greater Houston (HMO)	Greater Houston		Greater Houston	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H7993	002	0	2021	01	Devoted Health Prime Greater Houston (HMO)	Greater Houston		Greater Houston	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H7993	003	0	2021	01	Devoted Health Core San Antonio (HMO)	Bexar		Bexar	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H7993	004	0	2021	01	Devoted Health Prime San Antonio (HMO)	Bexar		Bexar	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	5501-6000 physicians and providers.	5501-6000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H8003	001	0	2021	04	BlueCross Total (PPO)	Upstate		Upstate	1	0	0	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H8003	002	0	2021	04	BlueCross Total (PPO)	Midlands/Coastal		Midlands/Coastal	1	0	0	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H8003	003	0	2021	04	BlueCross Total (PPO)	Lowcountry		Lowcountry	1	0	0	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H8003	004	0	2021	04	BlueCross Total Value (PPO)	Upstate		Upstate	1	0	0	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H8003	005	0	2021	04	BlueCross Total Value (PPO)	Midlands/Coastal		Midlands/Coastal	1	0	0	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
H8003	801	0	2021	04	BlueCross MAPD Calendar Year Group (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SCBluesMedAdvantage.com/retplan21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21
H8003	802	0	2021	04	BlueCross MAPD Non-calendar Year Group (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 100191		Columbia	SC	29202				P.O. Box 100191		Columbia	SC	29202				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SCBluesMedAdvantage.com/retplan21	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21
H8003	803	0	2021	04	BlueCross MA Only Calendar Year Group (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 100191		Columbia	SC	29202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SCBluesMedAdvantage.com/retplan21	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21
H8003	804	0	2021	04	BlueCross MA Only Non-calendar Year Group (PPO)	Nationwide		Nationwide	1	3	1	P.O. Box 100191		Columbia	SC	29202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SCBluesMedAdvantage.com/retplan21	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21	www.SCBluesMedAdvantage.com/retplan21
H8010	002	0	2021	01	Clover Health Classic (HMO)	Select NJ Counties		Select NJ Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H8010	003	0	2021	01	Clover Health Value (HMO)	Select NJ Counties		Select NJ Counties	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H8010	005	0	2021	01	Clover Health Classic (HMO)	Bexar County		Bexar County	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H8010	008	0	2021	01	Clover Health Classic (HMO)	El Paso County		El Paso County	1	0	0	30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				30 Montgomery Street, 15th Floor		Jersey City	NJ	07302				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cloverhealth.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.cloverhealth.com/en/members/find-provider	www.cloverhealth.com/en/members/find-pharmacy	www.cloverhealth.com/en/members/formulary
H8016	001	0	2021	48	OneCare Connect (Medicare-Medicaid Plan)	Orange County, California		Orange County, California	1	0	0	505 City Parkway West		Orange	CA	92868				505 City Parkway West		Orange	CA	92868				5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.caloptima.org/onecareconnect	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.caloptima.org/OneCareConnect	https://www.caloptima.org/en/ForMembers/OneCareConnect/FindAProvider/PharmacySearch.aspx	https://www.caloptima.org/en/ForMembers/OneCareConnect/Pharmacy.aspx
H8019	001	0	2021	01	SSM Health Plan Unity (HMO)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	PO Box 56099		Madison	WI	53705				PO Box 56099		Madison	WI	53705				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	wellfirsthealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	wellfirsthealth.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	002	0	2021	02	SSM Health Plan Integrity (HMO-POS)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	PO Box 56099		Madison	WI	53705				PO Box 56099		Madison	WI	53705				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	wellfirsthealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	wellfirsthealth.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	003	0	2021	02	SSM Health Plan Harmony (HMO-POS)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	PO Box 56099		Madison	WI	53705												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	wellfirsthealth.com	0	0	2	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	wellfirsthealth.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	004	0	2021	01	SSM Health Plan Companion (HMO)	St. Louis Metro Area		St. Louis Metro Area	1	0	0	PO Box 56099		Madison	WI	53705				PO Box 56099		Madison	WI	53705				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	wellfirsthealth.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	wellfirsthealth.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	801	0	2021	01	SSM EGWP MAPD CY (HMO)	St. Louis Metro Area		St. Louis Metro Area	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	wellfirstbenefits.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	wellfirstbenefits.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	802	0	2021	01	SSM EGWP MAPD Non CY (HMO)	St. Louis Metro Area		St. Louis Metro Area	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	wellfirstbenefits.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	wellfirstbenefits.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	803	0	2021	01	SSM EGWP MA Only (HMO)	St. Louis Metro Area		St. Louis Metro Area	1	3	1	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	wellfirstbenefits.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	wellfirstbenefits.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	804	0	2021	02	SSM EGWP MAPD CY (HMO-POS)	St. Louis Metro Area		St. Louis Metro Area	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	wellfirstbenefits.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	wellfirstbenefits.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	805	0	2021	02	SSM EGWP MAPD Non CY (HMO-POS)	St. Louis Metro Area		St. Louis Metro Area	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	wellfirstbenefits.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	wellfirstbenefits.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8019	806	0	2021	02	SSM EGWP MA Only (HMO-POS)	St. Louis Metro Area		St. Louis Metro Area	1	3	1	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	wellfirstbenefits.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	wellfirstbenefits.com/doctors	wellfirstbenefits.com	wellfirstbenefits.com
H8026	001	0	2021	48	Aetna Better Health Premier Plan (Medicare-Medicaid Plan)	Wayne, Macomb and Southwest Michigan Regions		Wayne, Macomb and Southwest Michigan Regions	1	0	0	7400 W. Campus Road, MC F494		New Albany	OH	43054				7400 W. Campus Road, MC F494		New Albany	OH	43054				9000000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.aetnabetterhealth.com/michigan	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.aetnabetterhealth.com/michigan	www.aetnabetterhealth.com/michigan	www.aetnabetterhealth.com/michigan
H8046	001	0	2021	48	Molina Dual Options (Medicare-Medicaid Plan)	Select counties in Illinois		Select counties in Illinois	1	0	0	1520 Kensington Road	Suite 212	Oak Brook	IL	60523				200 Oceangate	Suite 100	Long Beach	CA	90802				3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H8064	002	0	2021	04	FirstMedicare Direct PPO Plus (PPO)	Sandhills		Sandhills	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H8064	004	0	2021	04	FirstMedicare Direct PPO Premier (PPO)	Sandhills		Sandhills	1	0	0	42 Memorial Drive		Pinehurst	NC	28374				42 Memorial Drive		Pinehurst	NC	28374				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.firstmedicare.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.firstmedicare.com	www.firstmedicare.com	www.firstmedicare.com
H8067	001	0	2021	01	Provider Partners Maryland Advantage Plan (HMO I-SNP)	Western & Central Maryland		Western & Central Maryland	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H8067	003	0	2021	01	Provider Partners Maryland Community Plan (HMO I-SNP)	Western & Central Maryland		Western & Central Maryland	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H8082	001	0	2021	20	Stockton PACE (PACE)	Parts of Stanislaus and San Joaquin County in CA		Parts of Stanislaus and San Joaquin County in CA	1	3	0									582 E Harding Way		Stockton	CA	95204				5000000000208001630308001630408001630508001630608001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://stocktonpace.welbehealth.com/	0	0	1			0					3	0	0		https://www.omnicare.com/	N/A
H8082	002	0	2021	20	Stockton PACE - Medicare only (PACE)	Parts of Stanislaus and San Joaquin County in CA		Parts of Stanislaus and San Joaquin County in CA	1	3	0									582 E Harding Way		Stockton	CA	95204				5000000000200001630300001630400001630500001630600001630000000000	5000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://stocktonpace.welbehealth.com/	0	0	1			0					3	0	0		https://www.omnicare.com/	N/A
H8087	001	0	2021	04	HumanaChoice H8087-001 (PPO)	Select Counties in Michigan		Select Counties in Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	002	0	2021	04	Humana Value Plus H8087-002 (PPO)	Select counties in Michigan		Select counties in Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	003	0	2021	04	HumanaChoice SNP-DE H8087-003 (PPO D-SNP)	Select Counties in Michigan		Select Counties in Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	801	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	802	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	803	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	804	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	805	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	806	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	807	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	808	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	809	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8087	810	0	2021	04	Humana Medicare Employer (PPO)	Select Counties in Multi-States		Select Counties in Multi-States	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8093	001	0	2021	01	Georgia Health Advantage (HMO I-SNP)	Georgia		Georgia	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	GeorgiaHealthAdvantage.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	GeorgiaHealthAdvantage.com	GeorgiaHealthAdvantage.com	GeorgiaHealthAdvantage.com
H8096	001	0	2021	20	Centra PACE - Dual (PACE)	Centra PACE - Lynchburg, Farmville, & Gretna VA		Centra PACE - Lynchburg, Farmville, & Gretna VA	1	3	0									407 Federal Street		Lynchburg	VA	24504		george.graham@centrahealth.com	george.graham@centrahealth.com	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.centrapace.com	0	0	1			0					3	0	0		www.centrahealth.com	http:\\www.centrahealth.com
H8096	002	0	2021	20	Centra PACE - Medicare only (PACE)	Centra PACE - Lynchburg, Farmville, & Gretna VA		Centra PACE - Lynchburg, Farmville, & Gretna VA	1	3	0									407 Federal Street		Lynchburg	VA	24504		george.graham@centrahealth.com	george.graham@centrahealth.com	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.centrapace.com	0	0	1			0					3	0	0		www.centrahealth.com	http:\\www.centrahealth.com
H8125	002	0	2021	01	UnitedHealthcare Dual Complete LP1 (HMO D-SNP)	Select Counties in Ohio		Select Counties in Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H8125	003	0	2021	01	UnitedHealthcare Dual Complete LP1 (HMO D-SNP)	Select counties in Oklahoma		Select counties in Oklahoma	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
H8130	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Tampa, West Palm Beach and Miami Metro Areas		Tampa, West Palm Beach and Miami Metro Areas	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H8133	001	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	Houston Metro Area		Houston Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H8133	003	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	El Paso		El Paso	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $255.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $255.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H8133	005	0	2021	01	Blue Cross Medicare Advantage Basic (HMO)	South Texas		South Texas	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H8133	801	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Texas		Statewide in Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	getbluetx.com/mapd/providers	www.getbluetx/mapd/pharmacies	www.getbluetx/mapd/druglist
H8133	803	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Texas		Statewide in Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	getbluetx.com/mapd/providers	www.getbluetx/mapd/pharmacies	www.getbluetx/mapd/druglist
H8133	805	0	2021	01	Blue Cross Group Medicare Advantage Plan (HMO)	Statewide in Texas		Statewide in Texas	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	getbluetx.com/mapd	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	getbluetx.com/mapd/providers	www.getbluetx/mapd/pharmacies	www.getbluetx/mapd/druglist
H8142	001	0	2021	01	BSW SeniorCare Advantage Select Rx (HMO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	002	0	2021	01	BSW SeniorCare Advantage Preferred Rx (HMO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	003	0	2021	01	BSW SeniorCare Advantage Premium Rx (HMO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	004	0	2021	01	BSW SeniorCare Advantage Select (HMO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	005	0	2021	01	BSW SeniorCare Advantage Preferred (HMO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	006	0	2021	01	BSW SeniorCare Advantage Premium (HMO)	Central Texas		Central Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	007	0	2021	01	BSW SeniorCare Advantage Select Rx (HMO)	North Texas		North Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	008	0	2021	01	BSW SeniorCare Advantage Select (HMO)	North Texas		North Texas	1	0	0	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	801	0	2021	01	BSW SeniorCare Advantage EGWP CY Rx (HMO)	Central Texas		Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	802	0	2021	01	BSW SeniorCare Advantage EGWP CY (HMO)	Central Texas		Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	803	0	2021	01	BSW SeniorCare Advantage EGWP FY Rx (HMO)	Central Texas		Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502				1206 West Campus Drive		Temple	TX	76502				3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8142	804	0	2021	01	BSW SeniorCare Advantage EGWP FY (HMO)	Central Texas		Central Texas	1	3	1	1206 West Campus Drive		Temple	TX	76502												3107002000207002000307002000407002000507002000607002000707002000	3107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	advantage.swhp.org	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	https://portal.swhp.org/#/search	https://portal.swhp.org/#/search	advantage.swhp.org
H8145	004	0	2021	09	Humana Gold Choice H8145-004 (PFFS)	North Carolina-Virginia		North Carolina-Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	006	0	2021	09	Humana Gold Choice H8145-006 (PFFS)	Select Counties in Michigan and Wisconsin		Select Counties in Michigan and Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	008	0	2021	09	Humana Gold Choice H8145-008 (PFFS)	Select Counties in Illinois		Select Counties in Illinois	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	021	0	2021	09	Humana Gold Choice H8145-021 (PFFS)	Kentucky and West Virginia		Kentucky and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	032	0	2021	09	Humana Gold Choice H8145-032 (PFFS)	Select counties in Ohio and Indiana		Select counties in Ohio and Indiana	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	042	0	2021	09	Humana Gold Choice H8145-042 (PFFS)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	052	0	2021	09	Humana Gold Choice H8145-052 (PFFS)	Select Counties in Pennsylvania		Select Counties in Pennsylvania	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	055	0	2021	09	Humana Gold Choice H8145-055 (PFFS)	Pennsylvania and West Virginia		Pennsylvania and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	061	0	2021	09	Humana Gold Choice H8145-061 (PFFS)	Select Counties in Florida		Select Counties in Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	069	0	2021	09	Humana Gold Choice H8145-069 (PFFS)	Select Counties in Georgia and South Carolina		Select Counties in Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	075	0	2021	09	Humana Gold Choice H8145-075 (PFFS)	Select Counties in Alabama		Select Counties in Alabama	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	084	0	2021	09	Humana Gold Choice H8145-084 (PFFS)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	089	0	2021	09	Humana Gold Choice H8145-089 (PFFS)	Select Counties in IA, MN, MT, ND, SD		Select Counties in IA, MN, MT, ND, SD	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	091	0	2021	09	Humana Gold Choice H8145-091 (PFFS)	Select Counties in Virginia		Select Counties in Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	120	0	2021	09	Humana Gold Choice H8145-120 (PFFS)	Select Counties in AR, KS, MO and OK		Select Counties in AR, KS, MO and OK	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	121	0	2021	09	Humana Gold Choice H8145-121 (PFFS)	Select Counties in Illinois and Michigan		Select Counties in Illinois and Michigan	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	122	0	2021	09	Humana Gold Choice H8145-122 (PFFS)	Select Counties in Arkansas, Kansas and Oklahoma		Select Counties in Arkansas, Kansas and Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	123	0	2021	09	Humana Gold Choice H8145-123 (PFFS)	Select Counties in Colorado and New Mexico		Select Counties in Colorado and New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	125	0	2021	09	Humana Gold Choice H8145-125 (PFFS)	Select Counties in Missouri		Select Counties in Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8145	126	0	2021	09	Humana Gold Choice H8145-126 (PFFS)	Select Counties in Texas		Select Counties in Texas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8173	001	0	2021	01	Devoted Health Core (HMO)	Maricopa		Maricopa	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H8173	002	0	2021	01	Devoted Health Select (HMO)	Maricopa		Maricopa	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H8173	003	0	2021	01	Devoted Health Flex (HMO)	Maricopa		Maricopa	1	0	0	Devoted Health	PO Box 211037	Eagan	MN	55121				Devoted Health	PO Box 211037	Eagan	MN	55121				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.Devoted.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.Devoted.com	www.Devoted.com	www.Devoted.com
H8176	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H8176	002	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties In Ohio		Select Counties In Ohio	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H8181	001	0	2021	04	Blue Cross Blue Shield Nebraska MA Access PPO (PPO)	Omaha/ Lincoln Metro Area and Central Nebraska		Omaha/ Lincoln Metro Area and Central Nebraska	1	0	0	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				4000000000207002000307002000407002000507002000607002000000000000	4107002000207002000307002000407002000507002000607002000707002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H8181	801	0	2021	04	BCBSNE Employer Group PPO Rx CY (PPO)	Omaha/ Lincoln Metro Area and Central Nebraska		Omaha/ Lincoln Metro Area and Central Nebraska	1	3	1	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https//Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H8181	802	0	2021	04	BCBSNE Employer Group PPO CY (PPO)	Omaha/ Lincoln Metro Area and Central Nebraska		Omaha/ Lincoln Metro Area and Central Nebraska	1	3	1	PO Box 261276		Plano	TX	75026												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H8181	803	0	2021	04	BCBSNE Employer Group PPO Rx CY (PPO)	Omaha/ Lincoln Metro Area and Central Nebraska		Omaha/ Lincoln Metro Area and Central Nebraska	1	3	1	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H8181	804	0	2021	04	BCBSNE Employer Group PPO Rx CY (PPO)	Omaha/ Lincoln Metro Area and Central Nebraska		Omaha/ Lincoln Metro Area and Central Nebraska	1	3	1	PO Box 261276		Plano	TX	75026				PO Box 261276		Plano	TX	75026				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://Medicare.NebraskaBlue.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindADoc	https://Medicare.NebraskaBlue.com/MedicareAdvantage/FindAPharmacy	https://Medicare.NebraskaBlue.com/MedicareAdvantage/RXCost
H8189	001	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Southeastern, Northeastern, Central Counties		Southeastern, Northeastern, Central Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.mhswi.com	1	3	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.mhswi.com/findadoctor	allwell.mhswi.com/findadoctor	allwell.mhswi.com/formulary
H8197	001	0	2021	48	Molina Dual Options (Medicare-Medicaid Plan)	Bexar, Dallas, El Paso, Harris & Hidalgo counties		Bexar, Dallas, El Paso, Harris & Hidalgo counties	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				3108002100208002100308002100408002100508002100608002100708002100	3108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H8211	001	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Select Counties in West Virginia		Select Counties in West Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8211	002	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Select Counties in West Virginia		Select Counties in West Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8211	005	0	2021	04	AARP Medicare Advantage Patriot (PPO)	WV MAO LPPO		WV MAO LPPO	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8211	006	0	2021	04	AARP Medicare Advantage Choice Plan 3 (PPO)	WV Medical Deductible Plan		WV Medical Deductible Plan	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8211	007	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in MT Area		Select Counties in MT Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8213	001	0	2021	48	First Choice VIP Care Plus (Medicare-Medicaid Plan)	SC - 42 of 46 counties		SC - 42 of 46 counties	1	0	0	200 Stevens Drive		Philadelphia	PA	19113				200 Stevens Drive		Philadelphia	PA	19113				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	http://www.firstchoicevipcareplus.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	http://www.firstchoicevipcareplus.com	http://www.firstchoicevipcareplus.com	http://www.firstchoicevipcareplus.com
H8225	001	0	2021	01	Ascension Complete St. Vincent's Reward (HMO)	Jacksonville Metro Area		Jacksonville Metro Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-formulary
H8225	002	0	2021	01	Ascension Complete Sacred Heart Reward (HMO)	Pensacola Metro Area		Pensacola Metro Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $390.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $390.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-formulary
H8225	003	0	2021	01	Ascension Complete St. Vincent's Secure (HMO)	Jacksonville Metro Area		Jacksonville Metro Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-formulary
H8225	004	0	2021	01	Ascension Complete Sacred Heart Secure (HMO)	Pensacola Metro Area		Pensacola Metro Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	ascensioncomplete.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-findadoctor	ascensioncomplete.com/fl-formulary
H8258	001	0	2021	48	L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)	Los Angeles County		Los Angeles County	1	0	0	1055 West 7th Street		Los Angeles	CA	90017				1055 West 7th Street		Los Angeles	CA	90017				5000000000208002000308002000408002000508002000608002000000000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.calmediconnectla.org	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.calmediconnectla.org	www.calmediconnectla.org	www.calmediconnectla.org
H8280	001	0	2021	01	Bright Advantage (HMO)	Birmingham Area		Birmingham Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H8280	002	0	2021	01	Bright Advantage Plus (HMO)	Birmingham Area		Birmingham Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H8293	001	0	2021	01	Clear Spring Health Essential (HMO)	Central, Southern and Shenandoah Valley Virginia		Central, Southern and Shenandoah Valley Virginia	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	www.clearspringhealthcare.com	www.clearspringhealthcare.com	www.clearspringhealthcare.com
H8298	001	0	2021	01	Horizon NJ TotalCare (HMO D-SNP)	New Jersey		New Jersey	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105				3 Penn Plaza East, PP-12F		Newark	NJ	07105				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.Horizonblue.com/Medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	http://doctorfinder.horizonblue.com/	www.horizonblue.com/ma-pharmacy-search	www.horizonblue.com/ma-drug-search
H8332	001	0	2021	01	Aetna Medicare Value Plan (HMO)	San Antonio area		San Antonio area	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8332	002	0	2021	01	Aetna Medicare Value Plan (HMO)	Dallas and Surrounding Counties		Dallas and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8332	801	0	2021	01	Aetna Medicare Plan (HMO)	Texas		Texas	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8332	802	0	2021	01	Aetna Medicare Plan w/Rx (HMO)	Texas		Texas	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CO	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8343	001	0	2021	04	Amerivantage Choice (PPO)	Fort Bend Galveston Harris and Montgomery Counties		Fort Bend Galveston Harris and Montgomery Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		2000000000208002300308002300408002300508002300608002300000000000	2108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8343	002	0	2021	04	Amerivantage Choice (PPO)	Dallas, Denton, Tarrant Counties		Dallas, Denton, Tarrant Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		2000000000208002300308002300408002300508002300608002300000000000	2108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8343	003	0	2021	04	Amerivantage Choice (PPO)	Bexar County		Bexar County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		2000000000208002300308002300408002300508002300608002300000000000	2108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8364	002	0	2021	04	Bright Advantage Choice Plus (PPO)	Birmingham Area		Birmingham Area	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H8379	001	0	2021	01	PriorityMedicare D-SNP (HMO D-SNP)	68 lower peninsula Michigan counties		68 lower peninsula Michigan counties	1	0	0	1231 East Beltline NE		Grand Rapids	MI	49525				1231 East Beltline NE		Grand Rapids	MI	49525				2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.priorityhealth.com/dsnp	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.priorityhealth.com/dsnp	www.priorityhealth.com/dsnp	www.priorityhealth.com/dsnp
H8390	011	0	2021	01	CareSource Advantage (HMO)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ga/plans/medicare/	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $30.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $30.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ga/plans/medicare/benefits-services/pharmacy/drug-formulary/
H8390	012	0	2021	01	CareSource Advantage (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ga/plans/medicare/	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ga/plans/medicare/benefits-services/pharmacy/drug-formulary/
H8390	013	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ga/plans/medicare/	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ga/plans/medicare/benefits-services/pharmacy/drug-formulary/
H8390	014	0	2021	01	CareSource Advantage Zero Premium (HMO)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ga/plans/medicare/	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ga/plans/medicare/benefits-services/pharmacy/drug-formulary/
H8390	015	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 1		Region 1	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ga/plans/dsnp/	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ga/plans/dsnp/pharmacy/drug-formulary/
H8390	016	0	2021	01	CareSource Dual Advantage (HMO D-SNP)	Region 2		Region 2	1	0	0	P.O. Box 8738		Dayton	OH	45401				P.O. Box 8738		Dayton	OH	45401				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.caresource.com/ga/plans/dsnp/	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.caresource.com/providers	www.caresource.com	www.caresource.com/ga/plans/dsnp/pharmacy/drug-formulary/
H8423	001	0	2021	48	Cigna CarePlan MMP (Medicare-Medicaid Plan)	Valley	Cigna CarePlan MMP (Medicare-Medicaid Plan)	Valley	1	0	0	2208 Highway 121	Suite 210	Bedford	TX	76021			LetUsHelpYou@HealthSpring.com	2208 Highway 121	Suite 210	Bedford	TX	76021			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.CarePlanTX.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.CarePlanTX.com	www.mycignahealthspring.com	www.CarePlanTX.com
H8424	001	0	2021	20	Siouxland PACE, INC (PACE)	Siouxland PACE, INC		Siouxland PACE, INC	1	3	0									1200 Tri View Ave		Sioux City	IA	51103		randy.ehlers@unitypoint.org	randy.ehlers@unitypoint.org	3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.unitypoint.org/siouxcity/services-pace	0	0	1			0					3	0	0		https://www.unitypoint.org/siouxcity/services-pace.aspx	https://www.unitypoint.org/siouxcity/services-pace.aspx
H8424	002	0	2021	20	Siouxland PACE, INC (PACE)	Siouxland PACE, INC		Siouxland PACE, INC	1	3	0									1200 Tri View Ave		Sioux City	IA	51103		Randy.ehlers@unitypoint.org	randy.ehlers@unitypoint.org	3000000000208001630308001630408001630508001630608001630000000000	3000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.unitypoint.org/siouxcity/services-pace	0	0	1			0					3	0	0		https://www.unitypoint.org/siouxcity/services-pace.aspx	https://www.unitypoint.org/siouxcity/services-pace.aspx
H8432	007	0	2021	01	Empire MediBlue Dual Advantage (HMO D-SNP)	New York City Area		New York City Area	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	008	5	2021	01	Empire MediBlue Plus (HMO)	New York City Area		Bronx County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	008	6	2021	01	Empire MediBlue Plus (HMO)	New York City Area		Queens County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	008	7	2021	01	Empire MediBlue Plus (HMO)	New York City Area		Kings County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	009	0	2021	01	Empire MediBlue Plus (HMO)	Rockland and Westchester Counties		Rockland and Westchester Counties	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	010	0	2021	01	Empire MediBlue Plus (HMO)	Nassau County		Nassau County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	011	0	2021	01	Empire MediBlue Plus (HMO)	Suffolk County		Suffolk County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	015	0	2021	02	Empire MediBlue Choice (HMO-POS)	Kings County		Kings County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.empireblue.com/shop	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	016	0	2021	01	Empire MediBlue Select (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	027	0	2021	01	Empire MediBlue Select (HMO)	Select Counties in New York City		Select Counties in New York City	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	028	0	2021	01	Empire MediBlue Dual Advantage Select (HMO D-SNP)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	1	3	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	032	0	2021	01	Empire MediBlue Select (HMO)	Nassau County		Nassau County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	15001-16000 physicians and providers.	15001-16000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	033	0	2021	01	Empire MediBlue Select (HMO)	Suffolk County		Suffolk County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/shop	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	034	0	2021	01	Empire MediBlue Dual Advantage Select (HMO D-SNP)	Suffolk County		Suffolk County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	035	0	2021	01	Empire MediBlue Extra Select (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	036	0	2021	01	Empire MediBlue Core Select (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	037	1	2021	01	Empire MediBlue Core (HMO)	Select Plans in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	037	2	2021	01	Empire MediBlue Core (HMO)	Select Plans in New York		Saratoga County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	038	1	2021	01	Empire MediBlue Plus (HMO)	Select Counties in New York		Columbia, Delaware and Greene	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	038	2	2021	01	Empire MediBlue Plus (HMO)	Select Counties in New York		Select Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	039	1	2021	01	Empire MediBlue Dual Advantage (HMO D-SNP)	Select Counties in New York		Columbia, Delaware, Greene	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	039	2	2021	01	Empire MediBlue Dual Advantage (HMO D-SNP)	Select Counties in New York		Upstate Counties in New York	1	0	0	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 659404		San Antonio	TX	78265		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H8432	801	0	2021	01	Anthem MediBlue (HMO)	Select Counties in Maine		Select Counties in Maine	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	802	0	2021	01	Anthem MediBlue (HMO)	Select Counties in Maine		Select Counties in Maine	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	803	0	2021	01	Anthem MediBlue (HMO)	Maine - Select Counties		Maine - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	804	0	2021	01	Empire MediBlue (HMO)	New York - Select Counties		New York - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	805	0	2021	01	Empire MediBlue (HMO)	New York - Select Counties		New York - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	806	0	2021	01	Empire MediBlue (HMO)	New York - Select Counties		New York - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	807	0	2021	01	Anthem MediBlue (HMO)	Select Maine Counties		Select Maine Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	808	0	2021	01	Anthem MediBlue (HMO)	Select Maine counties		Select Maine counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	809	0	2021	01	Anthem MediBlue (HMO)	Select Maine Counties		Select Maine Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	810	0	2021	01	Anthem MediBlue (HMO)	Select Maine Counties		Select Maine Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	811	0	2021	01	Empire MediBlue (HMO)	Select New York Counties		Select New York Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	812	0	2021	01	Empire MediBlue (HMO)	Select New York Counties		Select New York Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	813	0	2021	01	Empire MediBlue (HMO)	Select New York Counties		Select New York Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	814	0	2021	01	Empire MediBlue (HMO)	Select New York Counties		Select New York Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8432	815	0	2021	01	Anthem MediBlue (HMO)	Select Maine Counties		Select Maine Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/me/medicare	0	0	2	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	0	www.anthem.com/me/medicare	www.anthem.com/me/medicare	www.anthem.com/me/medicare
H8432	816	0	2021	01	Empire MediBlue (HMO)	Select NY Counties		Select NY Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.empireblue.com/ny/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare	www.empireblue.com/ny/medicare
H8452	001	0	2021	48	CareSource MyCare Ohio (Medicare-Medicaid Plan)	Northeast, Northeast Central, East Central Ohio		Northeast, Northeast Central, East Central Ohio	1	0	0	P.O. Box 8738		Dayton	OH	45401		memberhelp@caresource.com	memberhelp@caresource.com	P.O. Box 8738		Dayton	OH	45401		memberhelp@caresource.com	memberhelp@caresource.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.caresource.com/MyCare/	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	https://memberportal.caresource.com/App/OH/FindADoctor/MyCare	www.caresource.com	www.caresource.com/MyCare/
H8457	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	New York (partial)		New York (partial)	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H8492	001	0	2021	01	Dignity Health Plan (HMO I-SNP)	Select Parishes in Louisiana		Select Parishes in Louisiana	1	0	0	950 West Causeway Approach		Mandeville	LA	70471		info@dignityhmo.com	info@dignityhmo.com	950 West Causeway Approach		Mandeville	LA	70471		info@dignityhmo.com	info@dignityhmo.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.dignityhealthplan.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.dignityhealthplan.com	www.dignityhealthplan.com	www.dignityhealthplan.com
H8547	001	0	2021	01	Blue Medicare Advocate Health (HMO)	Chicago Metro Area		Chicago Metro Area	1	0	0	P.O. Box 4555		Scranton	PA	18505				P.O. Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H8552	020	0	2021	04	Anthem MediBlue Access (PPO)	Orange County		Orange County	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare/ca	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $370.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $370.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/ca/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H8552	028	0	2021	04	Anthem MediBlue ESRD Care (PPO C-SNP)	Select Counties in California		Select Counties in California	1	0	0	P.O. Box 659404	3800 Buffalo Speedway, Suite 400	San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404	3800 Buffalo Speedway, Suite 400	San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare/ca	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $130.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $130.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/ca/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H8552	029	0	2021	04	Anthem MediBlue Access (PPO)	Select Counties in California		Select Counties in California	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare/ca	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $370.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $370.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.anthem.com/ca/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H8552	030	0	2021	04	Anthem MediBlue Dual Access (PPO D-SNP)	Select Counties in California		Select Counties in California	1	0	0	P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		P.O. Box 659404		San Antonio	TX	78265		seniornewenroll@bluecrossca.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare/ca	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.anthem.com/ca/medicare	https://shop.anthem.com/medicare/ca	https://shop.anthem.com/medicare/ca
H8552	801	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	802	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002000508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	803	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	805	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	806	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002000508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	807	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	808	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002000508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	809	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002000508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	810	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	811	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	812	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002000508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8552	813	0	2021	04	Anthem Medicare Preferred (PPO)	National		National	1	3	1	P.O. Box 110		Fond du Lac	WI	54936												2000000000208002100308002100408002000508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/medicare	www.anthem.com/medicare	www.anthem.com/medicare
H8553	001	0	2021	04	WellCare Premier (PPO)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H8553	002	0	2021	04	WellCare Patriot (PPO)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H8553	003	0	2021	04	WellCare Rx Plus (PPO)	Select counties in AZ		Select counties in AZ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H8554	001	0	2021	01	Blue Cross Medicare Advantage Value (HMO)	San Antonio		San Antonio	1	0	0	P.O. Box 4555		Scranton	PA	18505				P.O.Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H8578	001	0	2021	01	Health New England Medicare Premium (HMO)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	003	0	2021	01	Health New England Medicare Premium No Rx (HMO)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthnewengland.org/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	004	0	2021	01	Health New England Medicare Plus (HMO)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	009	0	2021	01	Health New England Medicare Basic No Rx (HMO)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthnewengland.org/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	012	0	2021	01	Health New England Medicare Value (HMO)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	016	0	2021	02	Health New England Medicare Select (HMO-POS)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	017	0	2021	01	Health New England Medicare Choice (HMO)	Hampden, Hampshire, Franklin, Berkshire Counties		Hampden, Hampshire, Franklin, Berkshire Counties	1	0	0	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	801	0	2021	02	Health New England Medicare Employer Group RX (HMO-POS)	United States		United States	1	3	1	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	802	0	2021	02	HNE Medicare Employer Group Calendar (HMO-POS)	United States		United States	1	3	1	One Monarch Place	Suite 1500	Springfield	MA	01144												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthnewengland.org/medicare	0	0	2	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8578	803	0	2021	02	HNE Medicare Employer Group Non-Calendar (HMO-POS)	United States		United States	1	3	1	One Monarch Place	Suite 1500	Springfield	MA	01144				One Monarch Place	Suite 1500	Springfield	MA	01144				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.healthnewengland.org/medicare	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare	www.healthnewengland.org/medicare
H8597	001	0	2021	01	Aetna Medicare Dual Complete Plan (HMO D-SNP)	Select Texas counties		Select Texas counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8597	002	0	2021	01	Aetna Medicare Dual Complete Plan (HMO D-SNP)	Dallas and Surrounding counties		Dallas and Surrounding counties	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8597	003	0	2021	01	Aetna Medicare Dual Complete Plan (HMO D-SNP)	Houston and Surrounding Counties		Houston and Surrounding Counties	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8604	010	0	2021	04	The Health Plan SecureChoice - Option II (PPO)	East Central OH		East Central OH	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H8604	011	0	2021	04	The Health Plan SecureChoice - Option II (PPO)	Southeastern OH, West Virginia		Southeastern OH, West Virginia	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H8604	013	0	2021	04	The Health Plan SecureChoice Capitol Plan (PPO)	Kanawha and Surrounding Counties		Kanawha and Surrounding Counties	1	0	0	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H8604	801	0	2021	04	The Health Plan SecureChoice - Employer (PPO)	Eastern Ohio and West Virginia, National		Eastern Ohio and West Virginia, National	1	3	1	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	The Health Plan	1110 Main Street	Wheeling	WV	26003		information@healthplan.org	information@healthplan.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.healthplan.org/medicare	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.healthplan.org	www.healthplan.org	www.healthplan.org
H8634	002	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	Bernalillo, Sandoval, Torrance and Valencia cntys		Bernalillo, Sandoval, Torrance and Valencia cntys	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/mapd	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluenm.com/mapd/providers	www.getbluenm.com/mapd/pharmacies	www.getbluenm.com/mapd/druglist
H8634	003	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	Chicago Metro Area		Chicago Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H8634	004	0	2021	04	Blue Cross Medicare Advantage Choice Premier (PPO)	Chicago Metro Area		Chicago Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H8634	007	0	2021	04	Blue Cross Medicare Advantage Choice Plus (PPO)	Springfield and Central Illinois		Springfield and Central Illinois	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H8634	008	0	2021	04	Blue Cross Medicare Advantage Classic (PPO)	Chicago Metro Area		Chicago Metro Area	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/mapd	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getblueil.com/mapd/providers	www.getblueil.com/mapd/pharmacies	www.getblueil.com/mapd/druglist
H8634	801	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Nationwide		Nationwide	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mybluemedicarenm.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.mybluemedicarenm.com	www.mybluemedicarenm.com	www.mybluemedicarenm.com
H8634	803	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Nationwide		Nationwide	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mybluemedicarenm.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.mybluemedicarenm.com	www.mybluemedicarenm.com	www.mybluemedicarenm.com
H8634	805	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Nationwide		Nationwide	1	3	1	PO Box 4555		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mybluemedicarenm.com	0	0	2	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	0					3	0	0	www.mybluemedicarenm.com	www.mybluemedicarenm.com	www.mybluemedicarenm.com
H8634	807	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mybluemedicareok.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.mybluemedicareok.com	www.mybluemedicareok.com	www.mybluemedicareok.com
H8634	809	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mybluemedicareok.com	0	0	1	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	1					3	0	0	www.mybluemedicareok.com	www.mybluemedicareok.com	www.mybluemedicareok.com
H8634	811	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mybluemedicareok.com	0	0	2	3501-4000 physicians and providers.	3501-4000 médicos y proveedores.	0					3	0	0	www.mybluemedicareok.com	www.mybluemedicareok.com	www.mybluemedicareok.com
H8634	813	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Nationwide		Nationwide	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H8634	815	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	Nationwide		Nationwide	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H8634	817	0	2021	04	Blue Cross Group Medicare Advantage Plan (PPO)	State of Illinois		State of Illinois	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.hcsc.com	www.myprime.com	www.myprime.com
H8649	003	0	2021	01	Aetna Advantra (HMO)	Northern Utah		Northern Utah	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8649	008	0	2021	01	Aetna Advantra Select (HMO)	Northeastern Utah		Northeastern Utah	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8649	801	0	2021	01	Aetna Altius Medicare Plan w/Rx (HMO)	Utah		Utah	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8649	803	0	2021	01	Aetna Altius Medicare Plan (HMO)	Utah		Utah	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H8655	004	0	2021	20	InnovAge Virginia PACE II, LLC (PACE)	InnovAge Virginia- Richmond and Peninsula		InnovAge Virginia- Richmond and Peninsula	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A-noformulary
H8655	005	0	2021	20	InnovAge Virginia PACE II, LLC Medicare ONLY (PACE)	InnovAge Virginia-Richmond and Peninsula		InnovAge Virginia-Richmond and Peninsula	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A-noformulary
H8677	001	0	2021	48	Molina Dual Options (Medicare-Medicaid Plan)	Counties: San Diego, parts of Riv. & S. Bernardino		Counties: San Diego, parts of Riv. & S. Bernardino	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H8677	002	0	2021	48	Molina Dual Options (Medicare-Medicaid Plan)	Los Angeles County		Los Angeles County	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.molinahealthcare.com/duals	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals	www.molinahealthcare.com/duals
H8711	001	0	2021	04	WellCare Premier (PPO)	Select counties in NJ		Select counties in NJ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H8711	002	0	2021	04	WellCare Absolute (PPO)	Select counties in NJ		Select counties in NJ	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H8748	002	0	2021	02	AARP Medicare Advantage Plan 1 (HMO-POS)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8748	008	0	2021	02	AARP Medicare Advantage Plus Plan 1 (HMO-POS)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8748	009	0	2021	02	AARP Medicare Advantage Plus Plan 2 (HMO-POS)	Select Counties in Georgia		Select Counties in Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8748	019	0	2021	02	AARP Medicare Advantage Patriot (HMO-POS)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8748	025	0	2021	02	AARP Medicare Advantage Plan 2 (HMO-POS)	Select Counties in South Carolina		Select Counties in South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8764	001	0	2021	01	Aspire Health Advantage (HMO)	Monterey County		Monterey County	1	0	0	10 Ragsdale Drive	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	10 Ragsdale Dr	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		1	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aspirehealthplan.org	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aspirehealthplan.org	www.aspirehealthplan.org	www.aspirehealthplan.org
H8764	002	0	2021	02	Aspire Health Plus (HMO-POS)	Monterey County		Monterey County	1	0	0	10 Ragsdale Drive	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	10 Ragsdale Drive	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		1	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.aspirehealthplan.org	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.aspirehealthplan.org	www.aspirehealthplan.org	www.aspirehealthplan.org
H8764	003	0	2021	01	Aspire Health Value (HMO)	Monterey County		Monterey County	1	0	0	10 Ragsdale Dr.	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	10 Ragsdale Dr	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		1	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aspirehealthplan.org	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aspirehealthplan.org	www.aspirehealthplan.org	www.aspirehealthplan.org
H8764	801	0	2021	02	Aspire Health Group Plus (HMO-POS)	Monterey County		Monterey County	1	3	1	10 Ragsdale Drive	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	10 Ragsdale Dr	Suite 101	Monterey	CA	93940		csrII@aspirehealthplan.org	csrII@aspirehealthplan.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.aspirehealthplan.org	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.aspirehealthplan.org	www.aspirehealthplan.org	www.aspirehealthplan.org
H8768	003	0	2021	04	AARP Medicare Advantage Choice (PPO)	Northwestern Illinois		Northwestern Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	005	0	2021	04	AARP Medicare Advantage Choice (PPO)	Chicago Metro Area		Chicago Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	006	0	2021	04	AARP Medicare Advantage Choice (PPO)	Toledo Metro Area		Toledo Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $170.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $170.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	007	0	2021	04	AARP Medicare Advantage Choice (PPO)	Central Ohio		Central Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $170.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $170.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	008	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Oklahoma City Metro Area		Oklahoma City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	009	0	2021	04	AARP Medicare Advantage Choice (PPO)	Tulsa Metro Area		Tulsa Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	010	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Chicago Metro Area		Chicago Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	011	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Northwestern Illinois		Northwestern Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	012	0	2021	04	AARP Medicare Advantage Choice (PPO)	Lexington Metro area & Southeastern Kentucky		Lexington Metro area & Southeastern Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	013	0	2021	04	AARP Medicare Advantage Choice (PPO)	Louisville Metro Area		Louisville Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	014	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Cleveland Metro Area		Cleveland Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	015	0	2021	04	AARP Medicare Advantage Walgreens (PPO)	Cincinnati/Dayton Metro Area		Cincinnati/Dayton Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	016	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Oklahoma City Metro Area		Oklahoma City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	017	1	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in IA		IA/IL Metros	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	017	2	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in IA		IA Rural	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	018	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties in IA		Select Counties in IA	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H8768	019	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties servicing Illinois		Select Counties servicing Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	020	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties servicing Kentucky		Select Counties servicing Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	021	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties servicing Ohio & Kentucky		Select Counties servicing Ohio & Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	022	0	2021	04	AARP Medicare Advantage Choice (PPO)	State of New Jersey		State of New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
H8768	023	0	2021	04	AARP Medicare Advantage Choice Plan 2 (PPO)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	024	0	2021	04	AARP Medicare Advantage Choice Plan 1 (PPO)	Omaha Metro area		Omaha Metro area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	025	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Kansas City Metro Area		Kansas City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	026	0	2021	04	AARP Medicare Advantage Choice (PPO)	Jefferson City and Columbia Metro Areas		Jefferson City and Columbia Metro Areas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	027	0	2021	04	AARP Medicare Advantage Choice (PPO)	Springfield Metro Area		Springfield Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	028	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Oklahoma City Metro Area		Oklahoma City Metro Area	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	029	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in North Mississippi		Select Counties in North Mississippi	1	0	0	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	030	0	2021	04	AARP Medicare Advantage Choice (PPO)	Select Counties in South Mississippi		Select Counties in South Mississippi	1	0	0	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8768	031	0	2021	04	AARP Medicare Advantage Patriot (PPO)	Select Counties in Mississippi		Select Counties in Mississippi	1	0	0	P.O. Box 30770	3838 N Causeway Blvd, Suite 2200	Salt Lake City	UT	84130		PHN.Sales@peopleshealth.com	PHN.member@peopleshealth.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
H8769	001	0	2021	20	Genesys PACE of Genesee County (PACE)	Counties: Genesee, Lap, Liv,  Shi, Tus		Counties: Genesee, Lap, Liv,  Shi, Tus	1	3	0									412 E. First Street		Flint	MI	48502		craig.berry@ascension.org	craig.berry@ascension.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	ascension.org/GenesysPACE	0	0	1			0					3	0	0		genesys.org/PACE	genesys.org/PACE
H8769	002	0	2021	20	Genesys PACE of Genesee County (PACE)	Counties: Genesee, Lap, Liv, Shi, Tus		Counties: Genesee, Lap, Liv, Shi, Tus	1	3	0									412 E First Street		Flint	MI	48502		annette.sivertson@ascension.org	craig.berry@ascension.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	ascension.org/GenesysPACE	0	0	1			0					3	0	0		genesys.org/PACE	genesys.org/PACE
H8777	001	0	2021	20	Complete Senior Care Dual (PACE)	Niagara, NY		Niagara, NY	1	3	0									1302 Main Street		Niagara Falls	NY	14301		dafoe@hanci.com	dafoe@hanci.com	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.completeseniorcare.org/	0	0	1			0					3	0	0		Pharmastar	Pharmastar
H8777	002	0	2021	20	Complete Senior Care Medicare Only (PACE)	Niagara, NY		Niagara, NY	1	3	0									1302 Main Street		Niagara Falls	NY	14301		dafoe@hanci.com	dafoe@hanci.com	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.completeseniorcare.org	0	0	1			0					3	0	0		Pharmastar	Pharmastar
H8783	001	0	2021	04	EssentiaCare Secure (PPO)	Northern MN and 3 County WI		Northern MN and 3 County WI	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H8783	002	0	2021	04	EssentiaCare Grand (PPO)	Northern MN and 3 County WI		Northern MN and 3 County WI	1	0	0	PO Box 52		Minneapolis	MN	55440		sales@ucare.org		PO Box 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	home.ucare.org/en-us/search-network	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H8783	003	0	2021	04	EssentiaCare Access (PPO)	St. Louis County, MN and 3 County WI		St. Louis County, MN and 3 County WI	1	0	0	PO BOX 52		Minneapolis	MN	55440		sales@ucare.org		PO BOX 52		Minneapolis	MN	55440		sales@ucare.org		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://home.ucare.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://search.ucare.org	https://home.ucare.org	https://home.ucare.org/en-us/search-network/formulary
H8786	001	0	2021	48	Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)	Select TX Service Areas	Amerigroup Plan de Medicare y Medicaid (Medicare-Medicaid Plan)	Select TX Service Areas	1	0	0	Amerigroup Texas, Inc.	5959 Corporate Dr.  Suite 1300	Houston	TX	77036				Amerigroup Texas, Inc.	5959 Corporate Dr.  Suite 1300	Houston	TX	77036				9000000000208002000308002000408002000508002000608002000000000000	9100000000208002000308002000408002000508002000608002000700000000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.myamerigroup.com/txmmp	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.myamerigroup.com/txmmp	https://www.myamerigroup.com/txmmp/	www.myamerigroup.com/txmmp
H8797	001	0	2021	01	Perennial Advantage Strive (HMO I-SNP)	Ohio (partial)		Ohio (partial)	1	0	0	1001 Kingsmill Parkway		Columbus	OH	43229				1001 Kingsmill Parkway		Columbus	OH	43229				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.perennialadvantage.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.perennialadvantage.com	www.placeholder.com	www.perennialadvantage.com
H8797	002	0	2021	01	Perennial Advantage Concierge (HMO C-SNP)	Ohio (partial)		Ohio (partial)	1	0	0	1001 Kingsmill Parkway		Columbus	OH	43229				1001 Kingsmill Parkway		Columbus	OH	43229				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.perennialadvantage.com	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.perennialadvantage.com	www.placeholder.com	www.perennialadvantage.com
H8800	001	0	2021	20	Total Senior Care - Dual (PACE)	Cattaraugus, Allegany and Chautauqua counties		Cattaraugus, Allegany and Chautauqua counties	1	3	0									519 North Union Street		Olean	NY	14760		rpadlo@totalseniorcare.org	rpadlo@totalseniorcare.org	2000000000208301630308301630408301630508301630608301630000000000	2000000000208301630308301630408301630508301630608301630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.totalseniorcare.org	0	0	1			0					3	0	0	www.totalseniorcare.org	totalseniorcare.org	www.totalseniorcare.org
H8800	002	0	2021	20	Total Senior Care - Medicare Small Only (PACE)	Cattaraugus, Allegany and Chautauqua counties		Cattaraugus, Allegany and Chautauqua counties	1	3	0									519 North Union Street		Olean	NY	14760		rpadlo@totalseniorcare.org	rpadlo@totalseniorcare.org	2000000000208301630308301630408301630508301630608301630000000000	2000000000208301630308301630408301630508301630608301630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.totalseniorcare.org	0	0	1			0					3	0	0	www.totalseniorcare.org	totalseniorcare.org	www.totalseniorcare.org
H8845	001	0	2021	01	Magellan Complete Care of Arizona (HMO D-SNP)	Gila, Maricopa, Pinal		Gila, Maricopa, Pinal	1	0	0	4801 E Washington Street	Suite 225	Phoenix	AZ	85034				4801 E Washington Street	Suite 225	Phoenix	AZ	85034				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	mccofaz.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	mccofaz.com	mccofaz.com
H8849	001	0	2021	01	Amerivantage Diabetes Care Plus (HMO C-SNP)	Tarrant County		Tarrant County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		2000000000208002300308002300408002300508002300608002300000000000	2108002300208002300308002300408002300508002300608002300708002300	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	6001-6500 physicians and providers.	6001-6500 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	002	0	2021	01	Amerivantage Care To You Plus (HMO I-SNP)	Harris, Tarrant, Bexar, Dallas, Travis Counties		Harris, Tarrant, Bexar, Dallas, Travis Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		2000000000208002300308002300408002300508002300608002300000000000	2108002300208002300308002300408002300508002300608002300708002300	0		0	1	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	1	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	003	0	2021	01	Amerivantage Diabetes Care Plus (HMO C-SNP)	Harris County		Harris County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	004	0	2021	01	Amerivantage Heart Care Plus (HMO C-SNP)	Harris County		Harris County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	005	0	2021	01	Amerivantage Lung Care Plus (HMO C-SNP)	Harris County		Harris County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	4	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	006	0	2021	01	Amerivantage Select Plus (HMO)	Bexar County		Bexar County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	007	0	2021	01	Amerivantage Plus (HMO)	El Paso County		El Paso County	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	008	1	2021	01	Amerivantage Classic Plus (HMO)	Select Counties in TX		Houston MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	008	2	2021	01	Amerivantage Classic Plus (HMO)	Select Counties in TX		Dallas Fort Worth MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	008	3	2021	01	Amerivantage Classic Plus (HMO)	Select Counties in TX		San Antonio MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	008	4	2021	01	Amerivantage Classic Plus (HMO)	Select Counties in TX		El Paso MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	008	5	2021	01	Amerivantage Classic Plus (HMO)	Select Counties in TX		Lubbock MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	008	6	2021	01	Amerivantage Classic Plus (HMO)	Select Counties in TX		Austin MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	009	0	2021	01	Amerivantage Select Plus (HMO)	Fort Bend, Harris, Montgomery Counties		Fort Bend, Harris, Montgomery Counties	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		9000000000208002300308002300408002300508002300608002300000000000	9108002300208002300308002300408002300508002300608002300708002300	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	010	1	2021	01	Amerivantage Dual Coordination Plus (HMO D-SNP)	Select Counties in TX		Houston MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	010	2	2021	01	Amerivantage Dual Coordination Plus (HMO D-SNP)	Select Counties in TX		Dallas Fort Worth MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	010	3	2021	01	Amerivantage Dual Coordination Plus (HMO D-SNP)	Select Counties in TX		San Antonio MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	010	4	2021	01	Amerivantage Dual Coordination Plus (HMO D-SNP)	Select Counties in TX		El Paso MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	010	5	2021	01	Amerivantage Dual Coordination Plus (HMO D-SNP)	Select Counties in TX		Lubbock MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	010	6	2021	01	Amerivantage Dual Coordination Plus (HMO D-SNP)	Select Counties in TX		Austin MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	011	1	2021	01	Amerivantage Dual Secure Plus (HMO D-SNP)	Select Counties in TX		Houston MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	011	2	2021	01	Amerivantage Dual Secure Plus (HMO D-SNP)	Select Counties in TX		Dallas Fort Worth MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	011	3	2021	01	Amerivantage Dual Secure Plus (HMO D-SNP)	Select Counties in TX		San Antonio MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	011	4	2021	01	Amerivantage Dual Secure Plus (HMO D-SNP)	Select Counties in TX		El Paso MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	011	5	2021	01	Amerivantage Dual Secure Plus (HMO D-SNP)	Select Counties in TX		Lubbock MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8849	011	6	2021	01	Amerivantage Dual Secure Plus (HMO D-SNP)	Select Counties in TX		Austin MSA	1	0	0	Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		Amerigroup Texas, Inc.	3800 Buffalo Speedway, Suite 400	Houston	TX	77098		seniornewenroll@bluecrossca.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.amerigroup.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
H8854	002	0	2021	01	Dual Prime (HMO D-SNP)	Select Maryland Counties	Dual Prime (HMO D-SNP)	Select Maryland Counties	1	0	0	1966 Greenspring Drive, Suite 100		Timonium	MD	21093		info@ummedicareadvantage.org	info@ummedicareadvantage.org	1966 Greenspring Drive, Suite 100		Timonium	MD	21093		info@ummedicareadvantage.org	info@ummedicareadvantage.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.ummedicareadvantage.org	1	3	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.ummedicareadvantage.org	www.ummedicareadvantage.org	www.ummedicareadvantage.org
H8889	001	0	2021	04	Medica Advantage Solution H8889-001 (PPO)	Minneapolis/St. Paul Metro Area		Minneapolis/St. Paul Metro Area	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H8889	002	0	2021	04	Medica Advantage Solution H8889-002 (PPO)	Select Counties in MN		Select Counties in MN	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H8889	003	0	2021	04	Medica Advantage Solution H8889-003 (PPO)	Minneapolis/St. Paul Metro Area		Minneapolis/St. Paul Metro Area	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H8889	004	0	2021	04	Medica Advantage Solution H8889-004 (PPO)	Southern Minnesota		Southern Minnesota	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H8889	005	0	2021	04	Medica Advantage Solution H8889-005 (PPO)	Minneapolis/St. Paul Metro Area		Minneapolis/St. Paul Metro Area	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H8889	801	0	2021	04	Medica Group Advantage Solution (PPO)	Select Counties in the US		Select Counties in the US	1	3	1	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medica.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	medica.com/Members	medica.com/Members	medica.com/Members
H8908	001	0	2021	01	Humana Gold Plus H8908-001 (HMO)	Detroit Area		Detroit Area	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	002	0	2021	01	Humana Gold Plus H8908-002 (HMO)	Grand Rapids area		Grand Rapids area	1	0	0	500 West Main St		Louisville	KY	40202				500 West Main St		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	004	0	2021	01	Humana Gold Plus H8908-004 (HMO)	Southeast Michigan		Southeast Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	005	0	2021	01	Humana Gold Plus SNP-DE H8908-005 (HMO D-SNP)	Select counties in Michigan		Select counties in Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	801	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Michigan		Select Counties in Michigan	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	802	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Michigan		Select Counties in Michigan	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	804	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Michigan		Select Counties in Michigan	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8908	805	0	2021	01	Humana Medicare Employer (HMO)	Select Counties in Michigan		Select Counties in Michigan	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H8961	001	0	2021	01	Oscar + Holy Cross + Memorial Health (HMO)	Broward County		Broward County	1	0	0	PO Box 62045		Phoenix	AZ	85082				PO Box 62045		Phoenix	AZ	85082				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.hioscar.com/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.hioscar.com/search	www.hioscar.com/search	www.hioscar.com/search
H8967	001	0	2021	01	Great Plains Medicare Advantage (HMO I-SNP)	North Dakota (partial)		North Dakota (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.greatplainsmedicareadvantage.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com
H8967	002	0	2021	01	Great Plains Medicare Advantage Gold (HMO I-SNP)	North Dakota (partial)		North Dakota (partial)	1	0	0	PO Box 2190		Glen Allen	VA	23058				PO Box 2190		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.greatplainsmedicareadvantage.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com	www.greatplainsmedicareadvantage.com
H9001	019	0	2021	01	NaviCare (HMO D-SNP)	Massachusetts except Dukes and Nantucket counties		Massachusetts except Dukes and Nantucket counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		navicaresupport@fallonhealth.org	navicaresupport@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		navicaresupport@fallonhealth.org	navicaresupport@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/navicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/navicare-pharmacy	fallonhealth.org/navicare-formulary
H9001	029	14	2021	01	Fallon Medicare Plus Saver No Rx HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Barnstable and Berkshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	www.fallonhealth.org/medicare-formulary
H9001	029	15	2021	01	Fallon Medicare Plus Saver No Rx HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	www.fallonhealth.org/medicare-formulary
H9001	029	16	2021	01	Fallon Medicare Plus Saver No Rx HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Franklin, Hampden and Hampshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	www.fallonhealth.org/medicare-formulary
H9001	029	17	2021	01	Fallon Medicare Plus Saver No Rx HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		BRI, ESS, MID, NOR, PLY and SUF Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	www.fallonhealth.org/medicare-formulary
H9001	030	14	2021	01	Fallon Medicare Plus Green HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Barnstable and Berkshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	030	15	2021	01	Fallon Medicare Plus Green HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	030	16	2021	01	Fallon Medicare Plus Green HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Franklin, Hampden and Hampshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	030	17	2021	01	Fallon Medicare Plus Green HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		BRI, ESS, MID, NOR, PLY and SUF Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	031	14	2021	01	Fallon Medicare Plus Blue HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Barnstable and Berkshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	031	15	2021	01	Fallon Medicare Plus Blue HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	031	16	2021	01	Fallon Medicare Plus Blue HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Franklin, Hampden and Hampshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	031	17	2021	01	Fallon Medicare Plus Blue HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		BRI, ESS, MID, NOR, PLY and SUF Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	032	14	2021	01	Fallon Medicare Plus Super Saver HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Barnstable and Berkshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	032	15	2021	01	Fallon Medicare Plus Super Saver HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	032	16	2021	01	Fallon Medicare Plus Super Saver HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Franklin, Hampden and Hampshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	032	17	2021	01	Fallon Medicare Plus Super Saver HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		BRI, ESS, MID, NOR, PLY and SUF Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	034	14	2021	01	Fallon Medicare Plus Orange HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Barnstable and Berkshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	034	15	2021	01	Fallon Medicare Plus Orange HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	034	16	2021	01	Fallon Medicare Plus Orange HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		Franklin, Hampden and Hampshire Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	034	17	2021	01	Fallon Medicare Plus Orange HMO (HMO)	Massachusetts except Dukes and Nantucket Counties		BRI, ESS, MID, NOR, PLY and SUF Counties	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	035	0	2021	01	Fallon Medicare Plus Central Blue HMO (HMO)	Worcester County		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.fallonhealth.org/FindPhysician	www.fallonhealth.org/medicare-pharmacy	www.fallonhealth.org/medicare-formulary
H9001	036	0	2021	01	Fallon Medicare Plus Central Green HMO (HMO)	Worcester County		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	037	0	2021	01	Fallon Medicare Plus Central Orange HMO (HMO)	Worcester County		Worcester County	1	0	0	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	803	0	2021	01	MA-PD HMO (HMO)	Full Service Area - Employer Groups		Full Service Area - Employer Groups	1	3	1	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	804	0	2021	01	MA-PD HMO PSP (HMO)	Full Service Area - Employer Groups		Full Service Area - Employer Groups	1	3	1	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	805	0	2021	01	MA-only HMO (HMO)	Full Service Area - Employer Groups		Full Service Area - Employer Groups	1	3	1	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	806	0	2021	01	MA-only non-calendar HMO (HMO)	Full Service Area - Employer Groups		Full Service Area - Employer Groups	1	3	1	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	12001-13000 physicians and providers.	12001-13000 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	807	0	2021	01	MA-only HMO PSP (HMO)	Full Service Area - Employer Groups		Full Service Area - Employer Groups	1	3	1	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9001	808	0	2021	01	MA-only non-calendar HMO PSP (HMO)	Full Service Area - Employer Groups		Full Service Area - Employer Groups	1	3	1	10 Chestnut Street		Worcester	MA	01608		contactcustomerservice@fallonhealth.org	contactcustomerservice@fallonhealth.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	fallonhealth.org/medicare	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	fallonhealth.org/FindPhysician	fallonhealth.org/medicare-pharmacy	fallonhealth.org/medicare-formulary
H9003	001	0	2021	01	Kaiser Permanente Senior Advantage Enhanced (HMO)	Portland-Vancouver Metro, Salem OR, Longview WA		Portland-Vancouver Metro, Salem OR, Longview WA	1	0	0	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	006	0	2021	01	Kaiser Permanente Senior Advantage Standard (HMO)	Portland-Vancouver Metro, Salem OR, Longview WA		Portland-Vancouver Metro, Salem OR, Longview WA	1	0	0	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	007	0	2021	01	Kaiser Permanente Senior Advantage Standard Lane (HMO)	Lane County		Lane County	1	0	0	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	008	0	2021	01	Kaiser Permanente Senior Advantage Value Lane (HMO)	Lane County		Lane County	1	0	0	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	009	0	2021	01	Kaiser Permanente Senior Advantage Value (HMO)	Portland-Vancouver Metro, Salem OR, Longview WA		Portland-Vancouver Metro, Salem OR, Longview WA	1	0	0	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	1	0	1	4	Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	801	0	2021	01	Employer Group Only with Part D (HMO)	Portland Metro, SW WA, Marion and Lane Counties		Portland Metro, SW WA, Marion and Lane Counties	1	3	1	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	802	0	2021	01	Employer Group Only without Part D (HMO)	Portland Metro, SW WA, Marion and Lane Counties		Portland Metro, SW WA, Marion and Lane Counties	1	3	1	500 NE Multnomah Suite 100		Portland	OR	97232												5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9003	805	0	2021	01	FEHB AB with D (HMO)	Portland Metro, SW WA, Marion and Lane Counties		Portland Metro, SW WA, Marion and Lane Counties	1	3	1	500 NE Multnomah Suite 100		Portland	OR	97232				500 NE Multnomah Suite 100		Portland	OR	97232				5108002000208002000308002000408002000508002000608002000708002000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	kp.org/medicare	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	kp.org/directory	kp.org/directory	kp.org/seniorrx
H9042	001	1	2021	04	MyTruAdvantage Choice (PPO)	Select Counties in Indiana		Segment 1	1	0	0	MyTruAdvantage	PO Box 428	Columbus	IN	47202				MyTruAdvantage	PO Box 428	Columbus	IN	47202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mytruadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mytruadvantage.com	www.mytruadvantage.com	www.mytruadvantage.com
H9042	001	2	2021	04	MyTruAdvantage Choice (PPO)	Select Counties in Indiana		Segment 2	1	0	0	MyTruAdvantage	PO Box 428	Columbus	IN	47202				MyTruAdvantage	PO Box 428	Columbus	IN	47202				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mytruadvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mytruadvantage.com	www.mytruadvantage.com	www.mytruadvantage.com
H9047	013	0	2021	01	Providence Medicare Extra Part B Only + RX (HMO)	Portland Metro and Willamette Valley		Portland Metro and Willamette Valley	1	3	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	033	0	2021	01	Providence Medicare Focus Medical (HMO)	Portland Metro, Willamette Valley, Clark County		Portland Metro, Willamette Valley, Clark County	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	2	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	035	0	2021	02	Providence Medicare Select Medical (HMO-POS)	Portland Metro, Willamette Valley, Clark County		Portland Metro, Willamette Valley, Clark County	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	2	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	037	0	2021	01	Providence Medicare Prime + RX (HMO)	Portland Metro		Portland Metro	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	038	0	2021	02	Providence Medicare Latitude + RX (HMO-POS)	Central OR, Hood River		Central OR, Hood River	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $120.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $120.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	039	0	2021	02	Providence Medicare Compass + RX (HMO-POS)	Central OR, Hood River		Central OR, Hood River	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	043	0	2021	01	Providence Medicare Dual Plus (HMO D-SNP)	Portland Metro		Portland Metro	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	045	0	2021	01	Providence Medicare Enrich + RX (HMO)	Linn and Benton Counties		Linn and Benton Counties	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	047	0	2021	02	Providence Medicare Summit + RX (HMO-POS)	Snohomish County		Snohomish County	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	049	0	2021	01	Providence Medicare Harbor + RX (HMO)	Snohomish County		Snohomish County	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $270.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $270.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	054	0	2021	01	Providence Medicare Timber + RX (HMO)	Columbia, Lane, Marion, Polk, Clark Counties		Columbia, Lane, Marion, Polk, Clark Counties	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	055	1	2021	01	Providence Medicare Extra + RX (HMO)	Portland Metro, Clark, Columbia, Lane, Marion,Polk		Portland Metro Area	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	055	2	2021	01	Providence Medicare Extra + RX (HMO)	Portland Metro, Clark, Columbia, Lane, Marion,Polk		Willamette Valley, Clark + Columbia Counties	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	056	1	2021	02	Providence Medicare Choice + RX (HMO-POS)	Portland Metro, Clark, Columbia, Lane, Marion,Polk		Portland Metro Area	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	056	2	2021	02	Providence Medicare Choice + RX (HMO-POS)	Portland Metro, Clark, Columbia, Lane, Marion,Polk		Columbia, Lane, Marion, Polk, Clark Counties	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	059	0	2021	02	Providence Medicare Bridge 1 + RX (HMO-POS)	Portland Metro Area		Portland Metro Area	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	060	0	2021	02	Providence Medicare Bridge 2 + RX (HMO-POS)	Clark, Columbia, Lane, Marion, Polk Counties		Clark, Columbia, Lane, Marion, Polk Counties	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	062	0	2021	02	Providence Medicare Cottonwood + RX (HMO-POS)	Spokane		Spokane	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	063	0	2021	01	Providence Medicare Pine + RX (HMO)	Spokane		Spokane	1	0	0	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	804	0	2021	01	Providence Medicare Align Group Plan + RX (HMO)	Portland, Willamette Valley,Central OR, Washington		Portland, Willamette Valley,Central OR, Washington	1	3	1	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	805	0	2021	02	Providence Medicare Flex Group Plan + RX (HMO-POS)	Portland, Willamette Valley,Central OR, Washington		Portland, Willamette Valley,Central OR, Washington	1	3	1	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	808	0	2021	01	Providence Medicare Align Group Plan + RX (HMO)	Portland, Willamette Valley,Central OR, Washington		Portland, Willamette Valley,Central OR, Washington	1	3	1	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9047	809	0	2021	02	Providence Medicare Flex Group Plan + RX (HMO-POS)	Portland, Willamette Valley,Central OR, Washington		Portland, Willamette Valley,Central OR, Washington	1	3	1	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.providencehealthassurance.com	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.providencehealthassurance.com/findaprovider	providencehealthassurance.com	providencehealthassurance.com
H9052	001	0	2021	20	Dual Eligible PACE 001 (PACE)	Counties: Huron, Sanilac, St. Clair, Tuscola,		Counties: Huron, Sanilac, St. Clair, Tuscola,	1	3	0									5229 Lakeshore Road		Fort Gratiot	MI	48059				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.	0	https://region7aaa.org/	0	0	1			0					3	0	0		N/A	N/A
H9052	002	0	2021	20	Medicare Only 002 (PACE)	Counties: Huron, Sanilac, Tuscola, St. Clair		Counties: Huron, Sanilac, Tuscola, St. Clair	1	3	0									5229 Lakeshore Road		Fort Gratiot	MI	48059				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		As submitted by organization	Como fue presentado a la organización.	0	https://region7aaa.org/	0	0	1			0					3	0	0		N/A	N/A
H9065	001	0	2021	01	Anthem l MaineHealth Advantage Dual Plus (HMO D-SNP)	State of Maine		State of Maine	1	0	0	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	002	0	2021	02	Anthem l MaineHealth Advantage Choice (HMO-POS)	Cumberland and York Counties		Cumberland and York Counties	1	0	0	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	003	0	2021	02	Anthem l MaineHealth Advantage Choice (HMO-POS)	Select Counties in ME		Select Counties in ME	1	0	0	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	004	0	2021	02	Anthem l MaineHealth Advantage Choice (HMO-POS)	Select Counties in ME		Select Counties in ME	1	0	0	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	005	0	2021	01	Anthem l MaineHealth Advantage Extra (HMO)	Cumberland and York Counties		Cumberland and York Counties	1	0	0	P.O. Box 110		Fond du Lac	WI	54936		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 110		Fond du Lac	WI	54936		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	006	0	2021	01	Anthem l MaineHealth Advantage Extra (HMO)	Select Counties in ME		Select Counties in ME	1	0	0	P.O. Box 110		Fond du Lac	WI	54936		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 110		Fond du Lac	WI	54936		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	007	0	2021	01	Anthem l MaineHealth Advantage Extra (HMO)	Select Counties in ME		Select Counties in ME	1	0	0	P.O. Box 110		Fond du Lac	WI	54936		mediblue@empireblue.com	mediblue@empireblue.com	P.O. Box 110		Fond du Lac	WI	54936		mediblue@empireblue.com	mediblue@empireblue.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9065	008	0	2021	01	Anthem l MaineHealth Advantage Plus (HMO)	Select Counties in Maine		Select Counties in Maine	1	0	0	P.O. Box 110		Fond du Lac	WI	54936				P.O. Box 110		Fond du Lac	WI	54936				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9066	001	0	2021	01	Nascentia Medicaid Advantage Plus (HMO D-SNP)	Upstate New York		Upstate New York	3	0	0	1050 West Genesee St		Syracuse	NY	13204				1050 West Genesee St		Syracuse	NY	13204				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.Nascentiahealthplus.org	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>Available to current members only.</li><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Solamente disponible a socios activos.</li><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Nascentiahealthplus.org	www.envisionrx.com	www.envisionrx.com
H9066	002	0	2021	01	Nascentia Skilled Nursing Facility (HMO I-SNP)	Upstate New York		Upstate New York	1	0	0	1050 West Genesee ST		Syracuse	NY	13204		nascentiahealth@477home.org	nascentiahealth@477home.org	1050 West Genesee ST		Syracuse	NY	13204		nascentiahealth@477home.org	nascentiahealth@477home.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.Nascentiahealthplus.org	1	1	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.Nascentiahealthplus.org	www.envisionrx.com	www.envisionrx.com
H9066	003	0	2021	01	Nascentia Dual Advantage (HMO D-SNP)	Upstate New York		Upstate New York	1	0	0	1050 West Genesee St		Syracuse	NY	13204				1050 West Genesee St		Syracuse	NY	13204				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.Nascentiahealthplus.org	1	3	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.Nascentiahealthplus.org	www.envisionrx.com	www.envisionrx.com
H9068	001	0	2021	20	Albright LIFE (PACE)	Lanc,Leb,Lyco,Union, part Chester,Clinton,North'd	Albright LIFE (PACE)	Lanc,Leb,Lyco,Union, part Chester,Clinton,North'd	1	3	0									90 Maplewood Drive		Lewisburg	PA	17837		pamela.kennedy@albrightcare.org	pamela.kennedy@albrightcare.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.albrightlife.org	0	0	1			0					3	0	0		www.albrightcare.org	www.albrightcare.org
H9068	002	0	2021	20	Albright LIFE Medicare Only (PACE)	Lanc,Leb,Lyco,Union, part Chester,Clinton,North'd	Albright LIFE Medicare Only (PACE)	Lanc,Leb,Lyco,Union, part Chester,Clinton,North'd	1	3	0									90 Maplewood Drive		Lewisburg	PA	17837		pamela.kennedy@albrightcare.org	pamela.kennedy@albrightcare.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.albrightlife.org	0	0	1			0					3	0	0		www.albrightcare.org	www.albrightcare.org
H9070	002	0	2021	04	Humana Value Plus H9070-002 (PPO)	Select Counties in Oklahoma		Select Counties in Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9070	003	0	2021	04	HumanaChoice H9070-003 (PPO)	Select Counties in Kansas and Missouri		Select Counties in Kansas and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9070	004	0	2021	04	HumanaChoice H9070-004 (PPO)	Select Counties in Kansas		Select Counties in Kansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9070	005	0	2021	04	HumanaChoice H9070-005 (PPO)	Select Counties in Arkansas		Select Counties in Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9070	006	1	2021	04	HumanaChoice H9070-006 (PPO)	Select Counties in Oklahoma		Oklahoma Rural	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9070	006	2	2021	04	HumanaChoice H9070-006 (PPO)	Select Counties in Oklahoma		Oklahoma City	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9070	006	3	2021	04	HumanaChoice H9070-006 (PPO)	Select Counties in Oklahoma		Tulsa	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	1					3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
H9082	009	0	2021	01	Molina Medicare Choice Care (HMO)	Select Counties in New Mexico		Select Counties in New Mexico	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H9095	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	Oklahoma (partial)		Oklahoma (partial)	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H9096	001	0	2021	02	Dean Advantage Assurance (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.deancare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.deancare.com/doctors	www.deancare.com	www.deancare.com
H9096	002	0	2021	02	Dean Advantage Balance (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.deancare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.deancare.com/doctors	www.deancare.com	www.deancare.com
H9096	004	0	2021	01	Dean Advantage Essential (HMO)	South Central Wisconsin		South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.deancare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.deancare.com/doctors	www.deancare.com	www.deancare.com
H9096	005	0	2021	01	Dean Advantage Complete (HMO)	South Central Wisconsin		South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.deancare.com/medicare	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.deancare.com/doctors	www.deancare.com	www.deancare.com
H9096	006	0	2021	02	Prevea360 Essential (HMO-POS)	North Eastern Wisconsin		North Eastern Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prevea360.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.prevea360.com/doctors	www.deancare.com	www.deancare.com
H9096	009	0	2021	02	Prevea360 Complete (HMO-POS)	North Eastern Wisconsin		North Eastern Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	www.prevea360.com/medicare	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.prevea360.com/doctors	www.deancare.com	www.deancare.com
H9096	010	0	2021	02	Dean Advantage Harmony (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717												2000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	deancare.com/medicare	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	deancare.com/doctors	www.deancare.com
H9096	011	0	2021	02	Prevea360 Harmony (HMO-POS)	North Eastern Wisconsin		North Eastern Wisconsin	1	0	0	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	prevea360.com/medicare	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	prevea360.com/doctors	www.deancare.com	www.deancare.com
H9096	801	0	2021	01	Dean Advantage - EGWP MAPD CY (HMO)	South Central Wisconsin		South Central Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.exploreyouradvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	802	0	2021	01	Dean Advantage - EGWP MAPD Non CY (HMO)	South Central Wisconsin		South Central Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.exploreyouradvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	803	0	2021	01	Dean Advantage - EGWP MA only (HMO)	South Central Wisconsin		South Central Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.exploreyouradvantage.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	804	0	2021	02	Dean Advantage EGWP CY HMOPOS (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.exploreyouradvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	805	0	2021	02	Dean Advantage EGWP Non CY HMOPOS (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.exploreyouradvantage.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	806	0	2021	02	Dean Advantage EGWP MA Only HMOPOS (HMO-POS)	South Central Wisconsin		South Central Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.exploreyouradvantage.com	0	0	2	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	807	0	2021	01	Prevea360 Medicare Advantage - EGWP MAPD CY (HMO)	North Eastern Wisconsin		North Eastern Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.exploreyouradvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	808	0	2021	01	Prevea360 Medicare Advantage - EGWP MAPD Non CY (HMO)	North Eastern Wisconsin		North Eastern Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.exploreyouradvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	809	0	2021	01	Prevea360 Medicare Advantage - EGWP MA Only (HMO)	North Eastern Wisconsin		North Eastern Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.exploreyouradvantage.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	810	0	2021	02	Prevea360 Medicare Advantage EGWP CY HMOPOS (HMO-POS)	North Eastern Wisconsin		North Eastern Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.exploreyouradvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	811	0	2021	02	Prevea360 Medicare Advantage EGWP Non CY HMOPOS (HMO-POS)	North Eastern Wisconsin		North Eastern Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717				1277 Deming Way		Madison	WI	53717				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.exploreyouradvantage.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9096	812	0	2021	02	Prevea360 Medicare Advantage EGWP MA Only HMOPOS (HMO-POS)	North Eastern Wisconsin		North Eastern Wisconsin	1	3	1	1277 Deming Way		Madison	WI	53717												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.exploreyouradvantage.com	0	0	2	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.exploreyouradvantage.com/doctors	www.deancare.com	www.deancare.com
H9104	006	0	2021	01	SCAN Healthy at Home (HMO I-SNP)	Los Angeles, Orange, and Inland Empire Areas	SCAN Healthy at Home (HMO I-SNP)	Los Angeles, Orange, and Inland Empire Areas	1	0	0	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	3800 Kilroy Airport Way	Suite 100	Long Beach	CA	90806		sales@scanhealthplan.com	memberservices@scanhealthplan.com	5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scanhealthplan.com	1	1	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.scanhealthplan.com	www.scanhealthplan.com	www.scanhealthplan.com
H9147	001	0	2021	01	Healthy Blue + Medicare (HMO D-SNP)	Select North Carolina Counties		Select North Carolina Counties	1	0	0	PO Box 17509		Winston Salem	NC	27116				PO Box 17509		Winston Salem	NC	27116				2000000000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	https://www.bluecrossnc.com/find-a-doctor-or-facility/medicare	https://www.myprime.com/MyRx/MyPrime/MedicareD/pharmacy/BCBSNC	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
H9153	001	0	2021	01	WV Senior Advantage (HMO I-SNP)	West Virginia (partial)		West Virginia (partial)	1	0	0	P.O. Box 94390		Lubbock	TX	79493				P.O. Box 94390		Lubbock	TX	79493				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.wvsenioradvantage.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.wvsenioradvantage.com	www.wvsenioradvantage.com	www.wvsenioradvantage.com
H9185	001	0	2021	20	Great Lakes PACE - Dual Eligible (PACE)	Great Lakes Bay Region: Saginaw, Midland, Bay, Tus		Great Lakes Bay Region: Saginaw, Midland, Bay, Tus	1	3	0									3378 Fashion Square Blvd		Saginaw	MI	48603			dbenjamin@greatlakespace.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.greatlakespace.org	0	0	1			0					3	0	0		www.greatlakespace.org	www.greatlakespace.org
H9185	002	0	2021	20	Great Lakes PACE (PACE)	Great Lakes Bay Region: Saginaw, Midland, Bay, Tus		Great Lakes Bay Region: Saginaw, Midland, Bay, Tus	1	3	0									3378 Fashion Square Blvd		Saginaw	MI	48603				2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.greatlakespace.org	0	0	1			0					3	0	0		www.greatlakespace.org	www.greatlakespace.org
H9191	001	0	2021	01	Provider Partners Missouri Advantage Plan (HMO I-SNP)	Select Missouri Counties		Select Missouri Counties	1	0	0	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	785 Elkridge Landing Rd, Suite 300		Linthicum Heights	MD	21090		info@pphealthplan.com	info@pphealthplan.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.pphealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.pphealthplan.com	www.pphealthplan.com	www.pphealthplan.com
H9207	002	0	2021	02	Health Partners Medicare Prime (HMO-POS)	Southeastern PA,Lehigh Capital PA,Carbon County PA		Southeastern PA,Lehigh Capital PA,Carbon County PA	1	0	0	901 Market Street	Suite 500	Philadelphia	PA	19107		MedicareInfo@HPPlans.com	MedicareInfo@HPPlans.com	901 Market Street	Suite 500	Philadelphia	PA	19107		MedicareInfo@HPPlans.com	MedicareInfo@HPPlans.com	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	HPPMedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	HPPMedicare.com	HPPMedicare.com	HPPMedicare.com
H9207	004	0	2021	01	Health Partners Medicare Special (HMO D-SNP)	Southeastern PA,Lehigh Capital PA,Carbon County PA		Southeastern PA,Lehigh Capital PA,Carbon County PA	1	0	0	901 Market Street	Suite 500	Philadelphia	PA	19107		MedicareInfo@HPPlans.com	MedicareInfo@HPPlans.com	901 Market Street	Suite 500	Philadelphia	PA	19107		MedicareInfo@HPPlans.com	MedicareInfo@HPPlans.com	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	HPPMedicare.com	1	3	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	HPPMedicare.com	HPPMedicare.com	HPPMedicare.com
H9207	012	0	2021	02	Health Partners Medicare Complete (HMO-POS)	Southeastern PA, Lehigh Capital PA, Carbon County		Southeastern PA, Lehigh Capital PA, Carbon County	1	0	0	901 Market Street	Suite 500	Philadelphia	PA	19107		MedicareInfo@HPPlans.com	MedicareInfo@HPPlans.com	901 Market Street	Suite 500	Philadelphia	PA	19107		MedicareInfo@HPPlans.com	MedicareInfo@HPPlans.com	2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	1	HPPMedicare.com	0	0	1	8501-9000 physicians and providers.	8501-9000 médicos y proveedores.	0					3	0	0	HPPMedicare.com	HPPMedicare.com	HPPMedicare.com
H9219	001	0	2021	04	Anthem l MaineHealth Advantage Access (PPO)	Select Counties in Maine		Select Counties in Maine	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9219	002	0	2021	04	Anthem l MaineHealth Advantage Access (PPO)	Select Counties in Maine		Select Counties in Maine	1	0	0	P.O. Box 659404		San Antonio	TX	78265				P.O. Box 659404		San Antonio	TX	78265				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9258	001	0	2021	01	WellCare Value (HMO)	All counties in RI		All counties in RI	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9266	001	0	2021	20	Piedmont Health SeniorCare - Dual (PACE)	Alamance, Caswell, Lee, Chatham, & Orange counties		Alamance, Caswell, Lee, Chatham, & Orange counties	1	3	0									1214 Vaughn Road		Burlington	NC	27217		ratclifm@piedmonthealth.org	ratclifm@piedmonthealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.piedmonthealthseniorcare.org/	0	0	1			0					3	0	0		noanswer	noanswer
H9266	003	0	2021	20	Piedmont Health SeniorCare - Medicare-only (PACE)	Alamance, Caswell, Orange, Lee, & Chatham counties		Alamance, Caswell, Orange, Lee, & Chatham counties	1	3	0									1214 Vaughn Road		Burlington	NC	27217		ratclifm@piedmonthealth.org	ratclifm@piedmonthealth.org	2000000000208001700308001700408001700508001700608001700000000000	2000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.piedmonthealthseniorcare.org/	0	0	1			0					3	0	0		noanswer	noanswer
H9276	021	0	2021	01	Allwell Medicare (HMO)	Palm Beach County		Palm Beach County	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunshinehealth.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/findadoctor	allwell.sunshinehealth.com/formulary
H9302	003	0	2021	01	Premera Blue Cross Medicare Advantage Charter + Rx (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H9302	004	0	2021	01	Premera Blue Cross Medicare Advantage Alpine (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	0	0	PO Box 262548		Plano	TX	75026												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	2	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H9302	007	0	2021	01	Premera Blue Cross Medicare Advantage Sound + Rx (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H9302	011	0	2021	01	Premera Blue Cross Medicare Advantage Peak + Rx (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	0	0	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $160.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $160.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H9302	801	0	2021	01	Premera Blue Cross Medicare Advantage + Rx (HMO)	Various Counties in Western WA		Various Counties in Western WA	1	3	1	PO Box 262548		Plano	TX	75026				PO Box 262548		Plano	TX	75026				5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	premera.com/ma	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	premera.com/ma	premera.com/ma	premera.com/ma
H9323	001	0	2021	20	Beacon of LIFE (PACE)	Monmouth County		Monmouth County	1	3	0									1075 Stephenson Avenue		Ocean Port	NJ	07757		info@beaconhss.com	info@beaconhss.com	2108001700208001700308001700408001700508001700608001700708001700	2108001700208001700308001700408001700508001700608001700708001700	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	beaconpace.com	0	0	1			0					3	0	0		NA	NA
H9323	002	0	2021	20	Beacon of LIFE (PACE)	Monmouth County		Monmouth County	1	3	0									1075 Stephenson Avenue		Ocean Port	NJ	07757		info@beaconhss.com	info@beaconhss.com	2108001700208001700308001700408001700508001700608001700708001700	2108001700208001700308001700408001700508001700608001700708001700	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	beaconpace.com	0	0	1			0					3	0	0		NA	NA
H9335	001	0	2021	01	WellCare Value (HMO)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9335	002	0	2021	01	WellCare Value (HMO)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	Below 250 physicians and providers.	Below 250 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9335	003	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9335	005	0	2021	01	WellCare Dividend (HMO)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9335	006	0	2021	01	WellCare Compass (HMO)	Select counties in MO		Select counties in MO	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9364	001	0	2021	01	WellCare Value (HMO)	All counties in ME		All counties in ME	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9364	002	0	2021	01	WellCare Access (HMO D-SNP)	All counties in ME		All counties in ME	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9364	003	0	2021	01	WellCare Liberty (HMO D-SNP)	All counties in ME		All counties in ME	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9387	001	0	2021	04	Allwell Medicare (PPO)	Eastern Kansas Counties		Eastern Kansas Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H9387	002	0	2021	04	Allwell Medicare Simple (PPO)	Eastern Kansas Counties		Eastern Kansas Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.sunflowerhealthplan.com	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/findadoctor	allwell.sunflowerhealthplan.com/formulary
H9403	001	0	2021	01	Clear Spring Health Deluxe Plan (HMO D-SNP)	Select South Carolina Counties		Select South Carolina Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H9403	003	0	2021	01	Clear Spring Health Silver Plan (HMO C-SNP)	Select South Carolina Counties		Select South Carolina Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	1	4	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H9403	004	0	2021	01	Clear Spring Health Select Plan (HMO)	Select South Carolina Counties		Select South Carolina Counties	1	0	0	P.O. Box 278530		Miramar	FL	33027				P.O. Box 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H9408	005	0	2021	04	Vibra Health Plan Enhanced Complete (PPO)	Southcentral and Northeast Pennsylvania		Southcentral and Northeast Pennsylvania	1	0	0	PO BOX 60250		Harrisburg	PA	17106				PO BOX 60250		Harrisburg	PA	17106				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	006	1	2021	04	Vibra Essential Advocate (PPO)	Southcentral and Northeast Pennsylvania		Southcentral Pennsylvania	1	0	0	PO BOX 60250		Harrisburg	PA	17106				PO BOX 60250		Harrisburg	PA	17106				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	006	2	2021	04	Vibra Essential Advocate (PPO)	Southcentral and Northeast Pennsylvania		Northeast Pennsylvania	1	0	0	PO BOX 60250		Harrisburg	PA	17106				PO BOX 60250		Harrisburg	PA	17106				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	801	0	2021	04	Vibra Group PPO Silver Rx (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106				PO BOX 60250		Harrisburg	PA	17106			medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	802	0	2021	04	Vibra Group PPO Bronze Rx FY (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106				PO BOX 60250		Harrisburg	PA	17106				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	803	0	2021	04	Vibra Group PPO Without Rx (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vibrahealthplan.com	https://www.vibrahealthplan.com/wps/portal/vhp/home/resources/drug-benefit	https://www.vibrahealthplan.com/wps/portal/vhp/home/resources/find-rx
H9408	804	0	2021	04	Vibra Group PPO Without Rx FY (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	2	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	0					3	0	0	www.vibrahealthplan.com	https://www.vibrahealthplan.com/wps/portal/vhp/home/resources/drug-benefit	https://www.vibrahealthplan.com/wps/portal/vhp/home/resources/find-rx
H9408	805	0	2021	04	Vibra Group PPO Platinum Rx (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	806	0	2021	04	Vibra Group PPO Gold Rx (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	807	0	2021	04	Vibra Group PPO Bronze Rx (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	808	0	2021	04	Vibra Group PPO Platinum Rx FY (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	809	0	2021	04	Vibra Group PPO Gold Rx FY (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9408	810	0	2021	04	Vibra Group PPO Silver Rx FY (PPO)	National		National	1	3	1	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	PO BOX 60250		Harrisburg	PA	17106		cbc.medicaresalesinquiries@capbluecross.com	medicareadvantagehmo@capbluecross.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vibrahealthplan.com	0	0	1	8001-8500 physicians and providers.	8001-8500 médicos y proveedores.	1					3	0	0	www.vibrahealthplan.com	www.vibrahealthplan.com	www.vibrahealthplan.com
H9412	803	0	2021	04	Geisinger Gold Preferred Rx  EGWP NJ (PPO)	Ocean & Monmouth Counties, NJ		Ocean & Monmouth Counties, NJ	1	3	1	100 North Academy Avenue		Danville	PA	17822				100 North Academy Avenue		Danville	PA	17822				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.GeisingerGold.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.GeisingerGold.com	www.GeisingerGold.com	www.GeisingerGold.com
H9428	001	0	2021	04	WellCare Premier (PPO)	Select counties in TN		Select counties in TN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $75.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $75.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9428	002	0	2021	04	WellCare Absolute (PPO)	Select counties in TN		Select counties in TN	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $90.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $90.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9431	001	0	2021	04	Aetna Medicare Choice Plan (PPO)	Central New Mexico		Central New Mexico	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	002	0	2021	04	Aetna Medicare Choice Plan (PPO)	Kootenai County		Kootenai County	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	003	0	2021	04	Aetna Medicare Select Plan (PPO)	Treasure Valley		Treasure Valley	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	004	0	2021	04	Aetna Medicare Choice Plan (PPO)	Southern Oregon		Southern Oregon	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	005	0	2021	04	Aetna Medicare Choice Plan (PPO)	Greater Portland Metro Area		Greater Portland Metro Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	006	0	2021	04	Aetna Medicare Choice Plan (PPO)	Treasure Valley		Treasure Valley	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	007	0	2021	04	Aetna Medicare Select Plan (PPO)	Southern Oregon		Southern Oregon	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	008	0	2021	04	Aetna Medicare Select Plan (PPO)	Greater Portland Metro Area		Greater Portland Metro Area	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@Aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	009	0	2021	04	Aetna Medicare Explorer Plan (PPO)	Rhode Island		Rhode Island	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	011	0	2021	04	Aetna Medicare Explorer Plan (PPO)	New Hampshire		New Hampshire	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	013	0	2021	04	Aetna Medicare Premier (PPO)	North Dakota		North Dakota	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7001-7500 physicians and providers.	7001-7500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	014	0	2021	04	Aetna Medicare Elite (PPO)	North Dakota		North Dakota	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	801	0	2021	04	Aetna First Health Medicare Plan (PPO)	Multi-State		Multi-State	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com									9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	2	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	0					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9431	802	0	2021	04	Aetna First Health Medicare Plan w/Rx (PPO)	Multi-State		Multi-State	1	3	1	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	151 Farmington Avenue		Hartford	CT	06156			SchulzF@Aetna.com	9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1					3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
H9438	001	0	2021	20	Bluestem PACE (PACE)	Counties:  RC, HV, RN, MN, MP, SA, EW, DK, OT, LC		Counties:  RC, HV, RN, MN, MP, SA, EW, DK, OT, LC	1	3	0									113 South Ash		McPherson	KS	67460				3000000000208002000308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluestempace.org	0	0	1			0					3	0	0		NA	NA
H9438	002	0	2021	20	Bluestem PACE (PACE)	Counties:  RC, HV, RN, MN, MP, SA, EW, DK, OT, LC		Counties:  RC, HV, RN, MN, MP, SA, EW, DK, OT, LC	1	3	0									113 South Ash		McPherson	KS	67460				3000000000208001700308001700408001700508001700608001700000000000	3000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluestempace.org	0	0	1			0					3	0	0		NA	NA
H9455	001	0	2021	01	Health Choice Generations Utah (HMO D-SNP)	Counties: Salt Lake, Utah, Davis, Weber, Tooele		Counties: Salt Lake, Utah, Davis, Weber, Tooele	1	0	0	6056 S. Fashion Square Drive	Suite 2400	Murray	UT	84107				6056 S. Fashion Square Drive	Suite 2400	Murray	UT	84107				4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.healthchoicegenerations.com	1	3	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.healthchoicegenerations.com	www.healthchoicegenerations.com	www.healthchoicegenerations.com
H9460	001	0	2021	01	Cigna Preferred Medicare (HMO)	Kansas City Area	Cigna Preferred Medicare (HMO)	Kansas City Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9460	002	0	2021	01	Cigna Fundamental Medicare (HMO)	Kansas City Area	Cigna Fundamental Medicare (HMO)	Kansas City Area	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9487	001	0	2021	48	Michigan Complete Health (Medicare-Medicaid Plan)	Wayne and Macomb Counties		Wayne and Macomb Counties	1	0	0	800 Tower Drive	Suite 200	Troy	MI	48098				800 Tower Drive	Suite 200	Troy	MI	48098				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	mmp.michigancompletehealth.com	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	mmp.michigancompletehealth.com/findadoctor	mmp.michigancompletehealth.com/findadoctor	mmp.michigancompletehealth.com/formulary
H9489	001	0	2021	01	Vermont Blue Advantage Unity HMO (HMO)	State of Vermont		State of Vermont	1	0	0	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9489	801	0	2021	01	Vermont Blue Advantage Group HMO (HMO)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9489	802	0	2021	02	Vermont Blue Advantage Group HMOPOS (HMO-POS)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9489	803	0	2021	01	Vermont Blue Advantage Group HMO (HMO)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9489	804	0	2021	02	Vermont Blue Advantage Group HMOPOS (HMO-POS)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9489	805	0	2021	01	Vermont Blue Advantage Group HMO (HMO)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9489	806	0	2021	02	Vermont Blue Advantage Group HMOPOS (HMO-POS)	State of Vermont		State of Vermont	1	3	1	P.O. Box 260160		Plano	TX	75026				P.O. Box 260160		Plano	TX	75026				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.vermontblueadvantage.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.vermontblueadvantage.com/findadoctor	www.vermontblueadvantage.com/pharmacies	www.vermontblueadvantage.com/formularies
H9516	001	0	2021	04	Bright Advantage Choice (PPO)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9516	002	0	2021	04	Bright Advantage Choice Plus (PPO)	Kings, New York, and Queens Counties		Kings, New York, and Queens Counties	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9525	003	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9525	004	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9525	006	0	2021	01	Anthem MediBlue Plus (HMO)	Select Counties in Wisconsin		Select Counties in Wisconsin	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9525	007	0	2021	01	Anthem MediBlue Dual Advantage (HMO D-SNP)	Kentucky		Kentucky	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9525	008	0	2021	01	Anthem MediBlue Plus (HMO)	Kentucky		Kentucky	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	1		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
H9525	801	0	2021	01	Anthem MediBlue (HMO)	Wisconsin select counties		Wisconsin select counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	802	0	2021	01	Anthem MediBlue (HMO)	Select counties in Wisconsin		Select counties in Wisconsin	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	803	0	2021	01	Anthem MediBlue (HMO)	Wisconsin - Select Counties		Wisconsin - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	804	0	2021	01	Anthem Senior Advantage (HMO)	Kentucky - Select Counties		Kentucky - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	805	0	2021	01	Anthem Senior Advantage (HMO)	Kentucky - Select Counties		Kentucky - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	806	0	2021	01	Anthem Senior Advantage (HMO)	Kentucky - Select Counties		Kentucky - Select Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	807	0	2021	01	Anthem MediBlue (HMO)	Select Wisconsin Coutnies		Select Wisconsin Coutnies	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	808	0	2021	01	Anthem MediBlue (HMO)	Select Wisconsin Counties		Select Wisconsin Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	809	0	2021	01	Anthem MediBlue (HMO)	Select Wisconsin Counties		Select Wisconsin Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	810	0	2021	01	Anthem MediBlue (HMO)	Select Wisconsin Counties		Select Wisconsin Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	811	0	2021	01	Anthem Senior Advantage (HMO)	Select Kentucky Counties		Select Kentucky Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	812	0	2021	01	Anthem Senior Advantage (HMO)	Select Kentucky Counties		Select Kentucky Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	813	0	2021	01	Anthem Senior Advantage (HMO)	Select Kentucky Counties		Select Kentucky Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	814	0	2021	01	Anthem Senior Advantage (HMO)	Select Kentucky Counties		Select Kentucky Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396				P.O. Box  110		Fond du Lac	WI	54396				2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9525	815	0	2021	01	Anthem MediBlue (HMO)	Select Wisconsin Counties		Select Wisconsin Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/wi/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare	www.anthem.com/wi/medicare
H9525	816	0	2021	01	Anthem Senior Advantage (HMO)	Select  KY Counties		Select  KY Counties	1	3	1	P.O. Box  110		Fond du Lac	WI	54396												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.anthem.com/ky/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare	www.anthem.com/ky/medicare
H9572	001	1	2021	04	Medicare Plus Blue PPO Signature (PPO)	State of Michigan		Region 1	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	001	2	2021	04	Medicare Plus Blue PPO Signature (PPO)	State of Michigan		Region 2	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	001	3	2021	04	Medicare Plus Blue PPO Signature (PPO)	State of Michigan		Region 3	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	001	4	2021	04	Medicare Plus Blue PPO Signature (PPO)	State of Michigan		Region 4	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	001	6	2021	04	Medicare Plus Blue PPO Signature (PPO)	State of Michigan		Region 6	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	002	1	2021	04	Medicare Plus Blue PPO Vitality (PPO)	State of Michigan		Region 1	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	002	2	2021	04	Medicare Plus Blue PPO Vitality (PPO)	State of Michigan		Region 2	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	002	3	2021	04	Medicare Plus Blue PPO Vitality (PPO)	State of Michigan		Region 3	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	002	4	2021	04	Medicare Plus Blue PPO Vitality (PPO)	State of Michigan		Region 4	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	002	6	2021	04	Medicare Plus Blue PPO Vitality (PPO)	State of Michigan		Region 6	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	003	1	2021	04	Medicare Plus Blue PPO Assure (PPO)	State of Michigan		Region 1	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	003	2	2021	04	Medicare Plus Blue PPO Assure (PPO)	State of Michigan		Region 2	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	003	3	2021	04	Medicare Plus Blue PPO Assure (PPO)	State of Michigan		Region 3	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	003	4	2021	04	Medicare Plus Blue PPO Assure (PPO)	State of Michigan		Region 4	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	003	6	2021	04	Medicare Plus Blue PPO Assure (PPO)	State of Michigan		Region 6	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	004	1	2021	04	Medicare Plus Blue PPO Essential (PPO)	State of Michigan		Region 1	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	004	2	2021	04	Medicare Plus Blue PPO Essential (PPO)	State of Michigan		Region 2	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	004	3	2021	04	Medicare Plus Blue PPO Essential (PPO)	State of Michigan		Region 3	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	004	4	2021	04	Medicare Plus Blue PPO Essential (PPO)	State of Michigan		Region 4	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	004	6	2021	04	Medicare Plus Blue PPO Essential (PPO)	State of Michigan		Region 6	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	801	0	2021	04	Medicare Plus Blue PPO Employer Rx CY (PPO)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	802	0	2021	04	Medicare Plus Blue PPO Employer CY (PPO)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226												2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	803	0	2021	04	Medicare Plus Blue PPO Employer Rx non-CY (PPO)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226				2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	804	0	2021	04	Medicare Plus Blue PPO Employer non-CY (PPO)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd	MC TC1302	Detroit	MI	48226												2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9572	805	0	2021	04	Medicare Plus Blue PPO Employer CY ASC (PPO)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226												2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.bcbsm.com/providersmedicare	www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
H9576	001	0	2021	48	Neighborhood INTEGRITY (Medicare-Medicaid Plan)	State of Rhode Island		State of Rhode Island	1	0	0	910 Douglas Pike		Smithfield	RI	02917				910 Douglas Pike		Smithfield	RI	02917				2000000000208002000308002000408002000508002000608002000708001200	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.nhpri.org/INTEGRITY	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.nhpri.org/INTEGRITY	https://www.nhpri.org/medicare-medicaid/find-a-provider-or-pharmacy/	https://www.nhpri.org/medicare-medicaid/member-materials/
H9585	001	0	2021	01	BMC HealthNet Plan Senior Care Options (HMO D-SNP)	Barnstable, Bristol, Hampden, Plymouth, Suffolk		Barnstable, Bristol, Hampden, Plymouth, Suffolk	1	0	0	529 Main Street	Suite 500	Charlestown	MA	02129				529 Main Street	Suite 500	Charlestown	MA	02129				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.SeniorsGetMore.org	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.SeniorsGetMore.org	www.SeniorsGetMore.org/pharmacy	www.SeniorsGetMore.org/pharmacy
H9589	003	0	2021	04	Clear Spring Health Choice Plan (PPO)	Select Georgia Counties		Select Georgia Counties	1	0	0	P.O. BOX 278530		Miramar	FL	33027				P.O. BOX 278530		Miramar	FL	33027				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.eonhealthplan.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.eonhealthplan.com	https://www.eonhp.com/	https://www.eonhp.com/
H9590	001	0	2021	01	Longevity Health Plan (HMO I-SNP)	Illinois (partial)		Illinois (partial)	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H9592	001	0	2021	20	Fresno PACE (PACE)	Fresno County Area		Fresno County Area	1	3	0									2042 Kern St		Fresno	CA	93721				5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fresnopace.org	0	0	1			0					3	0	0		www.fresnopace.org	www.pharmastarpbm.com/
H9592	002	0	2021	20	Fresno PACE (PACE)	Fresno County Area		Fresno County Area	1	3	0									2042 Kern St		Fresno	CA	93721				5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.fresnopace.org	0	0	1			0					3	0	0		www.fresnopace.org	www.pharmastarpbm.com/
H9615	007	0	2021	04	MVP Medicare WellSelect Plus with Part D (PPO)	S.Tier NY, Central NY, Eastern NY, Vermont		S.Tier NY, Central NY, Eastern NY, Vermont	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.joinMVPmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	008	0	2021	04	MVP Medicare WellSelect with Part D (PPO)	S.Tier NY, Central NY, Eastern NY, Vermont		S.Tier NY, Central NY, Eastern NY, Vermont	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.joinMVPmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	009	0	2021	04	MVP Medicare WellSelect Plus with Part D (PPO)	Hudson Valley NY		Hudson Valley NY	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.joinMVPmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	010	0	2021	04	MVP Medicare WellSelect with Part D (PPO)	Hudson Valley NY		Hudson Valley NY	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.joinMVPmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	012	0	2021	04	MVP Medicare WellSelect with Part D (PPO)	Western NY (Rochester/Buffalo)		Western NY (Rochester/Buffalo)	1	0	0	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.joinmvpmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	014	0	2021	04	MVP Medicare Patriot Plan with Part D (PPO)	Buffalo, Rochester, S. Tier, CNY, Capital, Hudson		Buffalo, Rochester, S. Tier, CNY, Capital, Hudson	1	0	0	220 Alexander St	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.joinmvpmedicare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	802	0	2021	04	MVP GoldAnywhere Rx - Employer Group (PPO)	Employer Group East/West NY, Vermont		Employer Group East/West NY, Vermont	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mvphealthcare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	807	0	2021	04	MVP USA Care Rx - Employer Group (PPO)	United States and Puerto Rico		United States and Puerto Rico	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mvphealthcare.com	0	0	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	1					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	810	0	2021	04	MVP GoldAnywhere - Employer Group (PPO)	Employer Group East/West NY, Vermont		Employer Group East/West NY, Vermont	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mvphealthcare.com	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9615	811	0	2021	04	MVP USA Care without Part D - Employer Group (PPO)	United States and Puerto Rico		United States and Puerto Rico	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mvphealthcare.com	0	0	2	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0					3	0	0	www.mvphealthcare.com	https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
H9616	001	0	2021	20	San Diego PACE (Duals) (PACE)	San Diego County		San Diego County	1	3	0									3364 Beyer Boulevard		San Ysidro	CA	92173		sdpace@syhc.org	sdpace@syhc.org	5000000000208001700308001700408001700508001700608001700000000000	5000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.syhc.org/sdpace/	0	0	1			0					3	0	0		http://www.syhc.org/services/senior-services/san-diego-pace/	http://www.syhc.org/services/senior-services/san-diego-pace/
H9616	002	0	2021	20	San Diego PACE (Medicare Only) (PACE)	San Diego County		San Diego County	1	3	0									3364 Beyer Boulevard, Suite 102		San Diego	CA	92173		juan.franco@syhc.org	juan.franco@syhc.org	5000000000208002000308002000408002000508002000608002000000000000	5000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.syhc.org/sdpace/	0	0	1			0					3	0	0		http://www.syhc.org/services/senior-services/san-diego-pace/	http://www.syhc.org/services/senior-services/san-diego-pace/
H9630	001	0	2021	01	Allwell Medicare (HMO)	Northwest Arkansas		Northwest Arkansas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	002	0	2021	01	Allwell Medicare (HMO)	Little Rock Area		Little Rock Area	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	003	0	2021	01	Allwell Medicare Select (HMO)	Benton, Washington Counties		Benton, Washington Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	004	0	2021	01	Allwell Medicare (HMO)	Little Rock Area and N. Arkansas Counties		Little Rock Area and N. Arkansas Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	005	0	2021	01	Allwell Medicare Premier (HMO)	Little Rock Area and N. Arkansas Counties		Little Rock Area and N. Arkansas Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	006	0	2021	01	Allwell Medicare Premier (HMO)	Northwest Arkansas		Northwest Arkansas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	008	0	2021	01	Allwell Medicare Boost (HMO)	Northwest Arkansas		Northwest Arkansas	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	009	0	2021	01	Allwell Medicare Simple (HMO)	Northwest Arkansas		Northwest Arkansas	1	0	0	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	2	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0					3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	801	0	2021	01	Allwell Group (HMO)	Arkansas		Arkansas	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	802	0	2021	01	Allwell Group (HMO)	Arkansas		Arkansas	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9630	803	0	2021	01	Allwell Group (HMO)	Arkansas		Arkansas	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.arhealthwellness.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/findadoctor	allwell.arhealthwellness.com/formulary
H9649	001	0	2021	20	Hope West PACE - Dual Eligible (PACE)	Mesa County		Mesa County	1	3	0									3090 N 12th Street, Unit B		Grand Junction	CO	81506		cmoores@hopewestco.org	cmoores@hopewestco.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.hopewestco.org/	0	0	1			0					3	0	0		https://www.hopewestco.org/	NA
H9649	002	0	2021	20	Hope West Pace - Medicare Only (PACE)	Mesa County		Mesa County	1	3	0									3090 N 12th Street, Unit B		Grand Junction	CO	81506		cmoores@hopewestco.org	cmoores@hopewestco.org	4000000000208001700308001700408001700508001700608001700000000000	4000000000208001700308001700408001700508001700608001700000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.hopewestco.org/	0	0	1			0					3	0	0		https://www.hopewestco.org/	NA
H9662	801	0	2021	01	Cigna Preferred Medicare (HMO)	Southern CA	Cigna Preferred Medicare (HMO)	Southern CA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9662	802	0	2021	01	Cigna Preferred Medicare FY (HMO)	Southern CA	Cigna Preferred Medicare FY (HMO)	Southern CA	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9686	001	0	2021	01	Platinum (HMO)	Clark County		Clark County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H9686	002	0	2021	01	NVPlus (HMO)	Clark County		Clark County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H9686	003	0	2021	01	AVA (HMO)	Clark County		Clark County	1	0	0	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com	lwendt@ahcusa.com	1100 W Town and Country Rd Suite 1300		Orange	CA	92868		Otorres@ahcusa.com		5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.alignmenthealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignmenthealthplan.com	www.alignmenthealthplan.com	www.alignmenthealthplan.com
H9699	004	1	2021	01	Health Advantage Blue Classic (HMO)	State of Arkansas		Northwest and West Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	http://www.arkansasbluecross.com	www.arkansasbluecross.com/medicare
H9699	004	2	2021	01	Health Advantage Blue Classic (HMO)	State of Arkansas		East Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	http://www.arkansasbluecross.com	www.arkansasbluecross.com/medicare
H9699	004	3	2021	01	Health Advantage Blue Classic (HMO)	State of Arkansas		Central AR counties	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	http://www.arkansasbluecross.com	www.arkansasbluecross.com/medicare
H9699	006	0	2021	01	Health Advantage Blue Premier (HMO)	Select Counties in West and Central AR		Select Counties in West and Central AR	1	0	0	P O Box 3648		Little Rock	AR	72203				P O Box 3648		Little Rock	AR	72203				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.arkansasbluecross.com	www.arkansasbluecross.com/medicare	www.arkansasbluecross.com/medicare
H9706	001	0	2021	01	Blue Cross Medicare Advantage Value (HMO)	Collin, Dallas, Denton, Tarrant		Collin, Dallas, Denton, Tarrant	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H9706	002	0	2021	01	Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)	State of Texas		State of Texas	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/dsnp	1	3	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.getbluetx.com/dsnp/providers	www.getbluetx.com/dsnp/pharmacies	www.getbluetx.com/dsnp/druglist
H9706	003	0	2021	01	Blue Cross Medicare Advantage Value (HMO)	Austin Metro		Austin Metro	1	0	0	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H9706	801	0	2021	01	Blue Cross Group Medicare Advantage (HMO)	Statewide in Texas		Statewide in Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H9706	802	0	2021	01	Blue Cross Group Medicare Advantage (HMO)	Statewide in Texas		Statewide in Texas	1	3	1	PO Box 4555		Scranton	PA	18505				PO Box 4555		Scranton	PA	18505				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	1	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H9706	803	0	2021	01	Blue Cross Group Medicare Advantage (HMO)	Statewide in Texas		Statewide in Texas	1	3	1	PO Box 4555		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/mapd	0	0	2	19001-20000 physicians and providers.	19001-20000 médicos y proveedores.	0					3	0	0	www.getbluetx.com/mapd/providers	www.getbluetx.com/mapd/pharmacies	www.getbluetx.com/mapd/druglist
H9712	001	0	2021	48	HAP Empowered MI Health Link (Medicare-Medicaid Plan)	Macomb and Wayne Counties		Macomb and Wayne Counties	1	0	0	PO Box 2578		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	mem_svcs@hap.org	PO Box 2578		Detroit	MI	48202		HAPMedicareAgent3@HAP.ORG	mem_svcs@hap.org	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.hap.org/mihealthlink	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.hap.org/mihealthlink	www.hap.org/mihealthlink	www.hap.org/mihealthlink
H9725	001	0	2021	01	Cigna Preferred Medicare (HMO)	North Carolina	Cigna Preferred Medicare (HMO)	North Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9725	003	0	2021	01	Cigna TotalCare (HMO D-SNP)	North Carolina	Cigna TotalCare (HMO D-SNP)	North Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	1	3	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9725	005	0	2021	01	Cigna Fundamental Medicare (HMO)	North Carolina	Cigna Fundamental Medicare (HMO)	North Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	2	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9725	006	0	2021	01	Cigna Preferred Plus Medicare (HMO)	North Carolina	Cigna Preferred Plus Medicare (HMO)	North Carolina	1	0	0	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092		seniors@cigna.com	LetUsHelpYou@HealthSpring.com	9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	6501-7000 physicians and providers.	6501-7000 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9725	801	0	2021	01	Cigna Preferred Medicare (HMO)	Statewide NC	Cigna Preferred Medicare (HMO)	Statewide NC	1	3	1	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	Attn: Member Services	2800 North Loop West	Houston	TX	77092			LetUsHelpYou@HealthSpring.com	9000000000208002000308002000408002000508002000608002000000000000	9000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0					3	0	0	www.cignamedicare.com	www.cigna.com/medicare	www.cignamedicare.com
H9730	002	0	2021	01	WellCare Value (HMO)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	16001-17000 physicians and providers.	16001-17000 médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	003	0	2021	01	WellCare Access (HMO D-SNP)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	004	0	2021	01	WellCare Liberty (HMO D-SNP)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	005	0	2021	02	WellCare Essential (HMO-POS)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	006	0	2021	02	WellCare Patriot (HMO-POS)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	1	www.wellcare.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	007	0	2021	01	WellCare Dividend (HMO)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	009	0	2021	01	WellCare Elite (HMO)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9730	010	0	2021	01	WellCare Compass (HMO)	Select counties in KY		Select counties in KY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.wellcare.com/medicare	www.wellcare.com/medicare	www.wellcare.com/medicare
H9808	004	0	2021	04	HealthTeam Advantage Plan I (PPO)	AL GL RA RO FOR DV DVS		AL GL RA RO FOR DV DVS	1	0	0	7800 McCloud Road	Suite 100	Greensboro	NC	27409		conciergehta@healthteamadvantage.com	conciergehta@healthteamadvantage.com	7800 McCloud Road	Suite 100	Greensboro	NC	27409		conciergehta@healthteamadvantage.com	conciergehta@healthteamadvantage.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthteamadvantage.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.healthteamadvantage.com	www.healthteamadvantage.com	www.healthteamadvantage.com
H9808	005	0	2021	04	HealthTeam Advantage Plan II (PPO)	AL GL RA RO FOR DV DVS		AL GL RA RO FOR DV DVS	1	0	0	7800 McCloud Road	Suite 100	Greensboro	NC	27409		conciergehta@healthteamadvantage.com	conciergehta@healthteamadvantage.com	7800 McCloud Road	Suite 100	Greensboro	NC	27409		conciergehta@healthteamadvantage.com	conciergehta@healthteamadvantage.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.healthteamadvantage.com	0	0	1	13001-14000 physicians and providers.	13001-14000 médicos y proveedores.	1					3	0	0	www.healthteamadvantage.com	www.healthteamadvantage.com	www.healthteamadvantage.com
H9811	001	0	2021	01	Allwell Medicare (HMO)	Counties: GE, HA, HR, HI, JA, MD, RA, ST		Counties: GE, HA, HR, HI, JA, MD, RA, ST	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	005	0	2021	01	Allwell Medicare (HMO)	Counties: DS, LA, PA, TA		Counties: DS, LA, PA, TA	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	006	0	2021	01	Allwell Dual Medicare (HMO D-SNP)	Counties: GE,HA, HR, HI, JA, MD, RA, ST		Counties: GE,HA, HR, HI, JA, MD, RA, ST	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	007	0	2021	01	Allwell Dual Medicare Essentials (HMO D-SNP)	Counties: GE, HA, HR, HI, JA, MD, RA, ST		Counties: GE, HA, HR, HI, JA, MD, RA, ST	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	1	3	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	008	0	2021	01	Allwell Medicare Boost (HMO)	George, Hancock, Harrison, and Jackson Counties		George, Hancock, Harrison, and Jackson Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	009	0	2021	01	Allwell Medicare Complement (HMO)	George, Hancock, Harrison, and Jackson Counties		George, Hancock, Harrison, and Jackson Counties	1	0	0	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	801	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	802	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	2	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9811	803	0	2021	01	Allwell Group (HMO)	Statewide		Statewide	1	3	1	PO Box 10420		Van Nuys	CA	91410				PO Box 10420		Van Nuys	CA	91410				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	allwell.magnoliahealthplan.com	0	0	1	2501-3000 physicians and providers.	2501-3000 médicos y proveedores.	0					3	0	0	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/findadoctor	allwell.magnoliahealthplan.com/formulary
H9826	001	0	2021	01	Community Health Choice (HMO D-SNP)	Southeast Texas		Southeast Texas	1	0	0	2636 South Loop West	Suite 125	Houston	TX	77054		memberservices@communityhealthchoice.org	memberservices@communityhealthchoice.org	2636 South Loop West	Suite 125	Houston	TX	77054		memberservices@communityhealthchoice.org	memberservices@communityhealthchoice.org	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.communityhealthchoice.org/medicare	1	3	1	4501-5000 physicians and providers.	4501-5000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.communityhealthchoice.org/medicare	www.communityhealthchoice.org/medicare	www.communityhealthchoice.org/medicare
H9830	001	0	2021	20	InnovAge Pennsylvania LIFE, LLC  - Dual (PACE)	InnovAge PA LIFE - North, NW, NE Phila Svc Area		InnovAge PA LIFE - North, NW, NE Phila Svc Area	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A
H9830	002	0	2021	20	InnovAge Pennsylvania LIFE, LLC - Medicare Only (PACE)	InnovAge PA LIFE - North, NW, NE Phila Svc Area		InnovAge PA LIFE - North, NW, NE Phila Svc Area	1	3	0									8950 E. Lowry Blvd.		Denver	CO	80230		dchase@myinnovage.com	dchase@myinnovage.com	2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.MyInnovAge.com	0	0	1			0					3	0	0		https://www.granerx.com/	N/A
H9834	001	0	2021	01	Gundersen MN Quartz Med Advantage Elite D (w/Rx) (HMO)	Counties: Fillmore, Houston, Wabasha, Winona		Counties: Fillmore, Houston, Wabasha, Winona	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H9834	003	0	2021	01	Gundersen MN Quartz Med Advantage Value D (w/Rx) (HMO)	Counties: Fillmore, Houston, Wabasha, Winona		Counties: Fillmore, Houston, Wabasha, Winona	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H9834	004	0	2021	01	Gundersen MN Quartz Med Advantage Value (HMO)	Counties: Fillmore, Houston, Wabasha, Winona		Counties: Fillmore, Houston, Wabasha, Winona	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H9834	005	0	2021	01	Gundersen MN Quartz Med Advantage Elite (HMO)	Counties: Fillmore, Houston, Wabasha, Winona		Counties: Fillmore, Houston, Wabasha, Winona	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	2	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	N/A	N/A
H9834	006	0	2021	01	Gundersen MN Quartz Med Advantage Core D (w/Rx) (HMO)	Counties: Fillmore, Houston, Wabasha, Winona		Counties: Fillmore, Houston, Wabasha, Winona	1	0	0	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	840 Carolina Street		Sauk City	WI	53583		customerservice@quartzbenefits.com	customerservice@quartzbenefits.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	quartzbenefits.com/medicareadvantage	0	0	1	10001-11000 physicians and providers.	10001-11000 médicos y proveedores.	0					3	0	0	quartzbenefits.com/MAFindaDoctor	quartzbenefits.com/MAFindaPharmacy	quartzbenefits.com/MAFormulary
H9842	001	0	2021	20	Saint Joseph PACE (PACE)	Partial Saint Joseph, Marshall & Elkhart counties		Partial Saint Joseph, Marshall & Elkhart counties	1	3	0									250 E. Day Rd.		Mishawaka	IN	46545		saintjosephpace@trinity-health.org	saintjosephpace@trinity-health.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	sjmed.com\PACE	0	0	1			0					3	0	0		TBD	TBD
H9842	002	0	2021	20	Saint Joseph PACE - Medicare Only (PACE)	Partial St. Joseph, Marshall & Elkhart Counties		Partial St. Joseph, Marshall & Elkhart Counties	1	3	0									250 E. Day Rd		Mishawaka	IN	46545		saintjosephpace@trinity-health.org	saintjosephpace@trinity-health.org	2000000000208001630308001630408001630508001630608001630000000000	2000000000208001630308001630408001630508001630608001630000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	sjmed.com\PACE	0	0	1			0					3	0	0		TBD	TBD
H9861	001	0	2021	01	Reliance Principle Plan (HMO)	Wayne, Oakland, Macomb, Genesee, St. Clair, Monroe		Wayne, Oakland, Macomb, Genesee, St. Clair, Monroe	1	0	0	23900 Orchard Lake Rd.	Suite 210	Farmington Hills	MI	48336		jnysson@relianceaco.org	jnysson@relianceaco.org	23900 Orchard Lake Rd.	Suite 210	Farmington Hills	MI	48336		jnysson@relianceaco.org	jnysson@relianceaco.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	RelianceMedicareAdvantage.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $125.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $125.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	RelianceMedicareAdvantage.org	RelianceMedicareAdvantage.org	RelianceMedicareAdvantage.org
H9861	002	0	2021	01	Reliance Cardinal Plan (HMO)	Wayne, Oakland, Macomb, Genesee, St. Clair, Monroe		Wayne, Oakland, Macomb, Genesee, St. Clair, Monroe	1	0	0	23900 Orchard Lake Rd.		Farmington Hills	MI	48336		jnysson@relianceaco.org	jnysson@relianceaco.org	23900 Orchard Lake Rd.	Suite 210	Farmington Hills	MI	48336		jnysson@relianceaco.org	jnysson@relianceaco.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	RelianceMedicareAdvantage.org	0	0	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0					3	0	0	RelianceMedicareAdvantage.org	RelianceMedicareAdvantage.org	RelianceMedicareAdvantage.org
H9861	003	0	2021	01	Reliance Dual Care Plus (HMO D-SNP)	Wayne, Oakland, Macomb, Genesee, St. Clair		Wayne, Oakland, Macomb, Genesee, St. Clair	1	0	0	23900 Orchard Lake Rd.	Suite 210	Farmington Hills	MI	48336				23900 Orchard Lake Rd.	Suite 210	Farmington Hills	MI	48336				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	RelianceMedicareAdvantage.org	1	3	1	4001-4500 physicians and providers.	4001-4500 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	RelianceMedicareAdvantage.org	RelianceMedicareAdvantage.org	RelianceMedicareAdvantage.org
H9869	001	0	2021	48	PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)	Counties: Ki, Qu, Brx, NY, Ri, Wes, Suf, Na, Rck		Counties: Ki, Qu, Brx, NY, Ri, Wes, Suf, Na, Rck	1	0	0	655 Third Avenue	2nd Floor	New York	NY	10017				655 Third Avenue	2nd Floor	New York	NY	10017				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare and Medicaid	Aprobado por Medicare y Medicaid	0	www.phpcares.org	0	0	1			0	<ul><li>This is a Medicare-Medicaid plan for people with both Medicare and Medicaid.  Contact the plan for details.</li></ul>	<ul><li>Este es un plan de Medicare-Medicaid para las personas que tienen ambos, Medicare y Medicaid. Llame al plan para detalles.</li></ul>			3	0	0	www.phpcares.org	www.phpcares.org	www.phpcares.org
H9870	001	0	2021	01	Passport Advantage (HMO D-SNP)	Jefferson and fifteen surrounding counties		Jefferson and fifteen surrounding counties	1	0	0	5100 Commerce Crossings Drive		Louisville	KY	40229				5100 Commerce Crossings Drive		Louisville	KY	40229				3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.passportadvantage.com	1	3	1	7501-8000 physicians and providers.	7501-8000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.passportadvantage.com	www.passportadvantage.com	www.passportadvantage.com
H9877	001	0	2021	01	Virginia Premier Advantage Elite (HMO D-SNP)	Central, Tidewater, Western, Roanoke, NOVA		Central, Tidewater, Western, Roanoke, NOVA	1	0	0	PO Box 4309		Richmond	VA	23220			vphpmedicareadvantage@virginiapremier.com	PO Box 4309		Richmond	VA	23220			vphpmedicareadvantage@virginiapremier.com	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.virginiapremier.com	1	3	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.virginiapremier.com	www.virginiapremier.com	www.virginiapremier.com
H9878	001	0	2021	04	Bright Advantage Choice (PPO)	Cincinnati, Toledo, and Youngstown Metro Areas		Cincinnati, Toledo, and Youngstown Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $50.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $50.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9878	002	0	2021	04	Bright Advantage Choice Plus (PPO)	Cincinnati, Toledo, and Youngstown Metro Areas		Cincinnati, Toledo, and Youngstown Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9878	003	0	2021	04	Bright Advantage University Hospitals Choice (PPO)	Cleveland and Akron Metro Areas		Cleveland and Akron Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9878	006	0	2021	04	Bright Advantage Flex Choice (PPO)	Cincinnati, Toledo, and Youngstown Metro Areas		Cincinnati, Toledo, and Youngstown Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9878	008	0	2021	04	Bright Advantage University Hospitals Choice Plus (PPO)	Cleveland and Akron Metro Areas		Cleveland and Akron Metro Areas	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9878	009	0	2021	04	Bright Advantage Choice (PPO)	Lorain County		Lorain County	1	0	0	Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				Bright Health Medicare Advantage – Enrollment	PO Box 853958	Richardson	TX	75085				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	https://brighthealthplan.com/medicare-advantage	0	0	1	2001-2500 physicians and providers.	2001-2500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/search?lob=hasMa	https://brighthealthplan.com/drug-search/ma/
H9909	001	0	2021	01	American Health Advantage of Mississippi (HMO I-SNP)	Mississippi		Mississippi	1	0	0	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	201 Jordan Road	Suite 200	Franklin	TN	37067		MemberServices@AmHealthPlans.com	MemberServices@AmHealthPlans.com	3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	ms.AmHealthPlans.com	1	1	1	1501-2000 physicians and providers.	1501-2000 médicos y proveedores.	0					3	0	0	ms.AmHealthPlans.com	ms.AmHealthPlans.com	ms.AmHealthPlans.com
H9917	001	0	2021	01	Align Thrive (HMO I-SNP)	Florida (partial)		Florida (partial)	1	0	0	8270 Woodland Center Blvd		Tampa	FL	33614				8270 Woodland Center Blvd		Tampa	FL	33614				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.alignseniorcare.com	1	1	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignseniorcare.com	www.alignseniorcare.com	www.alignseniorcare.com
H9917	002	0	2021	01	Align Connect (HMO C-SNP)	Florida (partial)		Florida (partial)	1	0	0	8270 Woodland Center Blvd		Tampa	FL	33614				8270 Woodland Center Blvd		Tampa	FL	33614				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	4	Approved by Medicare	Aprobado por Medicare	0	www.alignseniorcare.com	1	4	1	251-500 physicians and providers.	251-500 médicos y proveedores.	0					3	0	0	www.alignseniorcare.com	www.alignseniorcare.com	www.alignseniorcare.com
H9942	001	0	2021	04	Longevity Health Plan (PPO I-SNP)	New Jersey (partial)		New Jersey (partial)	1	0	0	PO Box 5850		Glen Allen	VA	23058				PO Box 5850		Glen Allen	VA	23058				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0	1	Approved by Medicare	Aprobado por Medicare	0	www.longevityhealthplan.com	1	1	1	501-1000 physicians and providers.	501-1000 médicos y proveedores.	1					3	0	0	www.longevityhealthplan.com	www.longevityhealthplan.com	www.longevityhealthplan.com
H9952	001	0	2021	01	Medica AccessAbility Solution Enhanced (HMO D-SNP)	Greater Minneapolis/St. Paul Metro Area		Greater Minneapolis/St. Paul Metro Area	1	0	0	401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		401 Carlson Parkway	CP 320	Minnetonka	MN	55305		MedicareConsultant@medica.com		3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	medica.com	1	3	1	17001-18000 physicians and providers.	17001-18000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	medica.com/ASE	medica.com/ASE	medica.com/ASE
H9955	001	0	2021	01	Molina Medicare Complete Care (HMO D-SNP)	Select Counties In Ohio		Select Counties In Ohio	1	0	0	200 Oceangate	Suite 100	Long Beach	CA	90802				200 Oceangate	Suite 100	Long Beach	CA	90802				2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.molinahealthcare.com/medicare	1	3	1	11001-12000 physicians and providers.	11001-12000 médicos y proveedores.	0	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare	www.molinahealthcare.com/medicare
H9998	001	0	2021	20	Silver Star - Dual (PACE)	Lubbock County		Lubbock County	1	3	0									P.O. Box 2828	4010 22nd Street	Lubbock	TX	79408		silverstar@starcarelubbock.org	silverstar@starcarelubbock.org	3000000000207301730307301730407301730507301730607301730000000000	3000000000207301730307301730407301730507301730607301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.silverstar.org	0	0	1			0					3	0	0		http://www.seniorscript.com/	www.silverstarlubbock.org
H9998	002	0	2021	20	Silver Star - Medicare only (PACE)	Lubbock County		Lubbock County	1	3	0									P.O. Box 2828	4010 22nd Street	Lubbock	TX	79408		silverstar@starcarelubbock.org	silverstar@starcarelubbock.org	3000000000207301730307301730407301730507301730607301730000000000	3000000000207301730307301730407301730507301730607301730000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.silverstar.org	0	0	1			0					3	0	0		http://www.seniorscript.com/	www.silverstarlubbock.org
R0110	001	0	2021	31	HumanaChoice R0110-001 (Regional PPO)	States of Louisiana and Mississippi		States of Louisiana and Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0110	003	0	2021	31	HumanaChoice R0110-003 (Regional PPO)	States of Louisiana and Mississippi		States of Louisiana and Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0110	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Louisiana and Mississippi		States of Louisiana and Mississippi	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0110	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Louisiana and Mississippi		States of Louisiana and Mississippi	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0759	001	0	2021	31	AARP Medicare Advantage Choice Plan 2 (Regional PPO)	Entire state of Florida		Entire state of Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
R0759	002	0	2021	31	AARP Medicare Advantage Patriot (Regional PPO)	Entire state of Florida		Entire state of Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
R0759	003	0	2021	31	UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)	State of Florida		State of Florida	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R0802	001	0	2021	31	Martin's Point Generations Advantage Flex (Regional PPO)	Northern New England (New Hampshire and Maine)		Northern New England (New Hampshire and Maine)	1	0	0	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	P.O. Box 9746	331 Veranda Street	Portland	ME	04104			gamemberservices@martinspoint.org	2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	MartinsPoint.org/Advantage	0	0	1	5001-5500 physicians and providers.	5001-5500 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage	MartinsPoint.org/Advantage
R0865	001	0	2021	31	HumanaChoice R0865-001 (Regional PPO)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0865	003	0	2021	31	HumanaChoice R0865-003 (Regional PPO)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $195.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $195.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0865	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0865	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0923	001	0	2021	31	HumanaChoice R0923-001 (Regional PPO)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0923	002	0	2021	31	HumanaChoice R0923-002 (Regional PPO)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0923	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Pennsylvania and West Verginia		States of Pennsylvania and West Verginia	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R0923	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Pennsylvania and West Verginia		States of Pennsylvania and West Verginia	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R1390	001	0	2021	31	HumanaChoice R1390-001 (Regional PPO)	States of North Carolina and Virginia		States of North Carolina and Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R1390	002	0	2021	31	HumanaChoice R1390-002 (Regional PPO)	States of North Carolina and Virginia		States of North Carolina and Virginia	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $360.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $360.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R1390	003	0	2021	31	Humana Honor R1390-003 (Regional PPO)	States of North Carolina and Virginia		States of North Carolina and Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R1390	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of North Carolina and Virginia		States of North Carolina and Virginia	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R1390	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of North Carolina and Virginia		States of North Carolina and Virginia	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R1532	001	0	2021	31	HumanaChoice R1532-001 (Regional PPO)	States of Arkansas and Missouri		States of Arkansas and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription-drugs/medicare_drug_tools/medicare_drug_list
R1532	002	0	2021	31	HumanaChoice R1532-002 (Regional PPO)	States of Arkansas and Missouri		States of Arkansas and Missouri	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription-drugs/medicare_drug_tools/medicare_drug_list
R1532	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Arkansas and Missouri		States of Arkansas and Missouri	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription-drugs/medicare_drug_tools/medicare_drug_list
R1532	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Arkansas and Missouri		States of Arkansas and Missouri	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription-drugs/medicare_drug_tools/medicare_drug_list
R1548	001	0	2021	31	UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)	North Carolina and Virginia		North Carolina and Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R2604	001	0	2021	31	UnitedHealthcare Medicare Advantage Choice (Regional PPO)	Georgia and South Carolina		Georgia and South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R2604	002	0	2021	31	UnitedHealthcare Medicare Silver (Regional PPO C-SNP)	Georgia and South Carolina		Georgia and South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R2604	003	0	2021	31	UnitedHealthcare Medicare Gold (Regional PPO C-SNP)	Georgia and South Carolina		Georgia and South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $210.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $210.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R2604	004	0	2021	31	UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)	Georgia and South Carolina		Georgia and South Carolina	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R2604	005	0	2021	31	UnitedHealthcare Medicare Advantage Patriot (Regional PPO)	Georgia and South Carolina		Georgia and South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R3175	003	0	2021	31	UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)	State of Hawaii		State of Hawaii	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	3001-3500 physicians and providers.	3001-3500 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R3175	801	0	2021	31	UnitedHealthcare Group Medicare Advantage (Regional PPO)	State of Hawaii		State of Hawaii	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	1					3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R3175	802	0	2021	31	UnitedHealthcare Group Medicare Advantage (Regional PPO)	State of Hawaii		State of Hawaii	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	1001-1500 physicians and providers.	1001-1500 médicos y proveedores.	0					3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R3332	001	0	2021	31	BlueMedicare Choice (Regional PPO)	State of Florida		State of Florida	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	FloridaBlue.com/medicare	FloridaBlue.com/medicare	MyPrime.com
R3392	001	0	2021	31	HumanaChoice R3392-001 (Regional PPO)	States of Georgia and South Carolina		States of Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R3392	002	0	2021	31	HumanaChoice R3392-002 (Regional PPO)	States of Georgia and South Carolina		States of Georgia and South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R3392	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Georgia and South Carolina		States of Georgia and South Carolina	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R3392	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Georgia and South Carolina		States of Georgia and South Carolina	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R3444	008	0	2021	31	UnitedHealthcare Medicare Silver (Regional PPO C-SNP)	Arkansas and Missouri	UnitedHealthcare Medicare Silver (Regional PPO C-SNP)	Arkansas and Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R3444	009	0	2021	31	UnitedHealthcare Medicare Gold (Regional PPO C-SNP)	Arkansas and Missouri	UnitedHealthcare Medicare Gold (Regional PPO C-SNP)	Arkansas and Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R3444	011	0	2021	31	UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)	Arkansas and Missouri	UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)	Arkansas and Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	18001-19000 physicians and providers.	18001-19000 médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R3444	012	0	2021	31	UnitedHealthcare Medicare Advantage Choice Plan 2 (Regional PPO)	Arkansas and Missouri	UnitedHealthcare Medicare Advantage Choice Plan 2 (Regional PPO)	Arkansas and Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R3444	023	0	2021	31	UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)	Arkansas and Missouri	UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)	Arkansas and Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R3887	001	0	2021	31	HumanaChoice R3887-001 (Regional PPO)	State of Michigan		State of Michigan	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tool/medicare_drug_list/
R3887	002	0	2021	31	HumanaChoice R3887-002 (Regional PPO)	State of Michigan		State of Michigan	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tool/medicare_drug_list/
R3887	801	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Michigan		State of Michigan	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tool/medicare_drug_list/
R3887	802	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Michigan		State of Michigan	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tool/medicare_drug_list/
R4182	001	0	2021	31	HumanaChoice R4182-001 (Regional PPO)	State of Texas		State of Texas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4182	003	0	2021	31	HumanaChoice R4182-003 (Regional PPO)	State of Texas		State of Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4182	004	0	2021	31	HumanaChoice R4182-004 (Regional PPO)	State of Texas		State of Texas	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $175.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $175.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4182	801	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Texas		State of Texas	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4182	802	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Texas		State of Texas	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http:www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4487	001	0	2021	31	Anthem MediBlue Access Basic (Regional PPO)	Indiana and Kentucky		Indiana and Kentucky	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
R4845	001	0	2021	31	HumanaChoice R4845-001 (Regional PPO)	States of Kansas and Oklahoma		States of Kansas and Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4845	002	0	2021	31	HumanaChoice R4845-002 (Regional PPO)	States of Kansas and Oklahoma		States of Kansas and Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4845	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Kansas and Oklahoma		States of Kansas and Oklahoma	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R4845	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Kansas and Oklahoma		States of Kansas and Oklahoma	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5329	001	0	2021	31	AARP Medicare Advantage Choice (Regional PPO)	Rural ME and NH		Rural ME and NH	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
R5342	001	0	2021	31	UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)	State of New York		State of New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5342	002	0	2021	31	UnitedHealthcare Medicare Advantage Patriot (Regional PPO)	State of New York		State of New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5342	005	0	2021	31	UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)	State of New York		State of New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $275.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $275.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5342	006	0	2021	31	UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)	State of New York		State of New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5342	801	0	2021	31	UnitedHealthcare Group Medicare Advantage (Regional PPO)	State of New York		State of New York	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5342	802	0	2021	31	UnitedHealthcare Group Medicare Advantage (Regional PPO)	State of New York		State of New York	1	3	1	PO Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	2	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	0					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5342	803	0	2021	31	UnitedHealthcare Group Medicare Advantage (Regional PPO)	New York		New York	1	3	1	PO Box 30770		Salt Lake City	UT	84130				PO Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com	0	0	1	14001-15000 physicians and providers.	14001-15000 médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R5361	001	0	2021	31	HumanaChoice R5361-001 (Regional PPO)	States of Illinois and Wisconsin		States of Illinois and Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5361	002	0	2021	31	HumanaChoice R5361-002 (Regional PPO)	States of Illinois and Wisconsin		States of Illinois and Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5361	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Illinois and Wisconsin		States of Illinois and Wisconsin	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5361	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Illnois and Wisconsin		States of Illnois and Wisconsin	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5495	001	0	2021	31	HumanaChoice R5495-001 (Regional PPO)	State of Ohio		State of Ohio	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5495	002	0	2021	31	HumanaChoice R5495-002 (Regional PPO)	State of Ohio		State of Ohio	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5495	801	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Ohio		State of Ohio	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5495	802	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Ohio		State of Ohio	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5826	005	0	2021	31	HumanaChoice R5826-005 (Regional PPO)	State of Florida		State of Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5826	018	0	2021	31	HumanaChoice R5826-018 (Regional PPO)	State of Florida		State of Florida	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5826	074	0	2021	31	HumanaChoice R5826-074 (Regional PPO)	State of Florida		State of Florida	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5826	805	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Florida		State of Florida	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5826	819	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Florida		State of Florida	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R5941	013	0	2021	31	Anthem MediBlue Access Core (Regional PPO)	Ohio		Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com										2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
R5941	014	0	2021	31	Anthem MediBlue Access Basic (Regional PPO)	Ohio		Ohio	1	0	0	1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		1351 William Howard Taft Road	CN14B-818	Cincinnati	OH	45206		medicaresales@anthem.com		2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $200.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $200.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.anthem.com	https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
R6694	003	0	2021	31	Aetna Medicare Premier Plus 1 (Regional PPO)	Ohio		Ohio	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
R6694	005	0	2021	31	Aetna Medicare Premier Plus 2 (Regional PPO)	Ohio		Ohio	1	0	0	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	P.O. Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $190.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $190.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
R6694	006	0	2021	31	Aetna Medicare Premier (Regional PPO)	New Jersey Counties: All		New Jersey Counties: All	1	0	0	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	PO Box 7405		London	KY	40742		GoldenMedicare@aetna.com	HicksJS@aetna.com	9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com	0	0	1	9001-10000 physicians and providers.	9001-10000 médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.aetnamedicare.com/findprovider	www.aetnamedicare.com/findpharmacy	www.aetnamedicare.com/formulary
R6801	008	0	2021	31	UnitedHealthcare Medicare Silver (Regional PPO C-SNP)	Texas	UnitedHealthcare Medicare Silver (Regional PPO C-SNP)	Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R6801	009	0	2021	31	UnitedHealthcare Medicare Gold (Regional PPO C-SNP)	Texas	UnitedHealthcare Medicare Gold (Regional PPO C-SNP)	Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	1	4	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R6801	011	0	2021	31	UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)	Texas	UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)	Texas	1	0	0	P.O. Box 30769		Salt Lake City	UT	84130				P.O. Box 30769		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.UHCCommunityPlan.com	1	3	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.</li><li>Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.</li></ul>	<ul><li>Éste es un plan Medicare para Necesidades Especiales para los beneficiarios que tienen Medicare y Medicaid. Para detalles, comuníquese con el plan.</li><li>Dependiendo de su nivel de Ayuda Adicional, podría pagar menos por los medicamentos que la cantidad del costo compartido que aparece listado. Busque en las cartas que recibe sobre la ayuda adicional o comuníquese con el plan para averiguar los costos exactos.</li></ul>			3	0	0	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com	www.UHCCommunityPlan.com
R6801	012	0	2021	31	UnitedHealthcare Medicare Advantage Choice (Regional PPO)	Texas	UnitedHealthcare MedicareComplete Choice (Regional PPO)	Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.UHCMedicareSolutions.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $395.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $395.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
R7220	001	0	2021	31	HumanaChoice R7220-001 (Regional PPO)	State of Arizona		State of Arizona	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7220	002	0	2021	31	HumanaChoice R7220-002 (Regional PPO)	State of Arizona		State of Arizona	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $420.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $420.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7220	801	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Arizona		State of Arizona	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7220	802	0	2021	31	Humana Medicare Employer (Regional PPO)	State of Arizona		State of Arizona	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7315	001	0	2021	31	HumanaChoice R7315-001 (Regional PPO)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0	<ul><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7315	002	0	2021	31	HumanaChoice R7315-002 (Regional PPO)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li><li>This plan's deductible only applies to out-of-network services.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li><li>El deducible de este plan sólo se aplica a los servicios fuera de la red.</li></ul>			3	0	1	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7315	801	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	3	1	500 West Main Street		Louisville	KY	40202				500 West Main Street		Louisville	KY	40202				9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7315	802	0	2021	31	Humana Medicare Employer (Regional PPO)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	3	1	500 West Main Street		Louisville	KY	40202												9000000000208002100308002100408002100508002100608002100000000000	9108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare	0	0	2	20001 and above physicians and providers.	20001 and above médicos y proveedores.	0					3	0	0	www.humana.com/members/tools	https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
R7444	001	0	2021	31	AARP Medicare Advantage Choice (Regional PPO)	New England		New England	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130				P.O. Box 30770		Salt Lake City	UT	84130				9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com	0	0	1	20001 and above physicians and providers.	20001 and above médicos y proveedores.	1	<ul><li>This plan does not charge an annual deductible for all drugs.  The $295.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $295.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5593	002	0	2021	29	Blue Rx PDP Plus (PDP)	Pennsylvania  and West Virginia		Pennsylvania  and West Virginia	1	0	0	Senior Markets Enrollment Department	P.O. Box 535049	Pittsburgh	PA	15253		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com		0	3			0					3	0	0		medicare.highmark.com	medicare.highmark.com
S5593	003	0	2021	29	Blue Rx PDP Complete (PDP)	Pennsylvania  and West Virginia		Pennsylvania  and West Virginia	1	0	0	Senior Markets Enrollment Department	P.O. Box 535049	Pittsburgh	PA	15253		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com		0	3			0					3	0	0		medicare.highmark.com	medicare.highmark.com
S5593	801	0	2021	29	Blue Rx PDP Employer Group Calendar (PDP)	National		National	1	3	1	Senior Markets Enrollment Department	P.O. Box 535049	Pittsburgh	PA	15253		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com		0	3			0					3	0	0		medicare.highmark.com	medicare.highmark.com
S5593	802	0	2021	29	Blue Rx PDP Employer Group Non-Calendar (PDP)	National		National	1	3	1	Senior Markets Enrollment Department	P.O. Box 535049	Pittsburgh	PA	15253		Chris.Scarnati@highmark.com	Chris.Scarnati@highmark.com									2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	medicare.highmark.com		0	3			0					3	0	0		medicare.highmark.com	medicare.highmark.com
S5921	348	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	349	0	2021	29	AARP MedicareRx Saver Plus (PDP)	New Jersey		New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	350	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Delaware, Maryland and Washington D.C.		Delaware, Maryland and Washington D.C.	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	351	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Pennsylvania and West Virginia		Pennsylvania and West Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	352	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Virginia		Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					1	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	353	0	2021	29	AARP MedicareRx Saver Plus (PDP)	North Carolina		North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	354	0	2021	29	AARP MedicareRx Saver Plus (PDP)	South Carolina		South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	355	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Georgia		Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	356	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Florida		Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					1	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	357	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Alabama and Tennessee		Alabama and Tennessee	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	358	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Michigan		Michigan	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	359	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Ohio		Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	360	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Indiana and Kentucky		Indiana and Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	361	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	362	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Illinois		Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	363	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Missouri		Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	364	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Arkansas		Arkansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	365	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Mississippi		Mississippi	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	366	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Louisiana		Louisiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					1	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	367	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Texas		Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	368	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	369	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Kansas		Kansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	370	0	2021	29	AARP MedicareRx Saver Plus (PDP)	IA, MN, MT, ND, NE, SD, WY		IA, MN, MT, ND, NE, SD, WY	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					1	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	371	0	2021	29	AARP MedicareRx Saver Plus (PDP)	New Mexico		New Mexico	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	372	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Colorado		Colorado	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	373	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Nevada		Nevada	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	374	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Oregon and Washington		Oregon and Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	375	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Idaho and Utah		Idaho and Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	376	0	2021	29	AARP MedicareRx Saver Plus (PDP)	California		California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	377	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Alaska		Alaska	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	378	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Maine and New Hampshire		Maine and New Hampshire	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	379	0	2021	29	AARP MedicareRx Saver Plus (PDP)	New York		New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	380	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Arizona		Arizona	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					1	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	381	0	2021	29	AARP MedicareRx Saver Plus (PDP)	Hawaii		Hawaii	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	382	0	2021	29	AARP MedicareRx Walgreens (PDP)	New York		New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	383	0	2021	29	AARP MedicareRx Walgreens (PDP)	Florida		Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	384	0	2021	29	AARP MedicareRx Walgreens (PDP)	Northern New England		Northern New England	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	385	0	2021	29	AARP MedicareRx Walgreens (PDP)	Central New England		Central New England	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	386	0	2021	29	AARP MedicareRx Walgreens (PDP)	New Jersey		New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	387	0	2021	29	AARP MedicareRx Walgreens (PDP)	Mid-Atlantic		Mid-Atlantic	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	388	0	2021	29	AARP MedicareRx Walgreens (PDP)	Pennsylvania and West Virginia		Pennsylvania and West Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	389	0	2021	29	AARP MedicareRx Walgreens (PDP)	Virginia		Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	390	0	2021	29	AARP MedicareRx Walgreens (PDP)	North Carolina		North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	391	0	2021	29	AARP MedicareRx Walgreens (PDP)	South Carolina		South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	392	0	2021	29	AARP MedicareRx Walgreens (PDP)	Georgia		Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	393	0	2021	29	AARP MedicareRx Walgreens (PDP)	Alabama and Tennessee		Alabama and Tennessee	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	394	0	2021	29	AARP MedicareRx Walgreens (PDP)	Michigan		Michigan	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	395	0	2021	29	AARP MedicareRx Walgreens (PDP)	Ohio		Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	396	0	2021	29	AARP MedicareRx Walgreens (PDP)	Indiana and Kentucky		Indiana and Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	397	0	2021	29	AARP MedicareRx Walgreens (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	398	0	2021	29	AARP MedicareRx Walgreens (PDP)	Illinois		Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	399	0	2021	29	AARP MedicareRx Walgreens (PDP)	Missouri		Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	400	0	2021	29	AARP MedicareRx Walgreens (PDP)	Arkansas		Arkansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	401	0	2021	29	AARP MedicareRx Walgreens (PDP)	Mississippi		Mississippi	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	402	0	2021	29	AARP MedicareRx Walgreens (PDP)	Louisiana		Louisiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	403	0	2021	29	AARP MedicareRx Walgreens (PDP)	Texas		Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	404	0	2021	29	AARP MedicareRx Walgreens (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	405	0	2021	29	AARP MedicareRx Walgreens (PDP)	Kansas		Kansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	406	0	2021	29	AARP MedicareRx Walgreens (PDP)	Upper Midwest and Northern Plains		Upper Midwest and Northern Plains	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	407	0	2021	29	AARP MedicareRx Walgreens (PDP)	New Mexico		New Mexico	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	408	0	2021	29	AARP MedicareRx Walgreens (PDP)	Colorado		Colorado	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	409	0	2021	29	AARP MedicareRx Walgreens (PDP)	Arizona		Arizona	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	410	0	2021	29	AARP MedicareRx Walgreens (PDP)	Nevada		Nevada	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	411	0	2021	29	AARP MedicareRx Walgreens (PDP)	Oregon and Washington		Oregon and Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	412	0	2021	29	AARP MedicareRx Walgreens (PDP)	Idaho and Utah		Idaho and Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	413	0	2021	29	AARP MedicareRx Walgreens (PDP)	California		California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	414	0	2021	29	AARP MedicareRx Walgreens (PDP)	Hawaii		Hawaii	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	415	0	2021	29	AARP MedicareRx Walgreens (PDP)	Alaska		Alaska	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	1	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5921	802	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5921	837	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5916	001	0	2021	29	Regence Medicare Script Basic (PDP)	Region of Idaho and Utah		Region of Idaho and Utah	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.regence.com/medicare	www.regence.com/medicare
S5916	002	0	2021	29	Regence Medicare Script Enhanced (PDP)	Region of Idaho and Utah		Region of Idaho and Utah	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare		0	3			0					3	0	0		www.regence.com/medicare	www.regence.com/medicare
S5916	802	0	2021	29	Regence Medicare Script (PDP)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare		0	3			0					3	0	0		www.regence.com/medicare	www.regence.com/medicare
S5916	804	0	2021	29	Regence Medicare Script 02 (PDP)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare		0	3			0					3	0	0		www.regence.com/medicare	www.regence.com/medicare
S5916	805	0	2021	29	Regence Medicare Script 03 (PDP)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.regence.com/medicare		0	3			0					3	0	0		www.regence.com/medicare	www.regence.com/medicare
S5753	006	0	2021	29	WPS MedicareRx Plan 1 (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	1717 W. Broadway	P.O. Box 8190	Madison	WI	53708		medicaresolutions@wpsic.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wpsmedicaredrugs.com		0	3			0					3	0	0		www.wpsmedicaredrugs.com	www.wpsmedicaredrugs.com
S5753	007	0	2021	29	WPS MedicareRx Plan 2 (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	1717 W. Broadway	P.O. Box 8190	Madison	WI	53708		medicaresolutions@wpsic.com										3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wpsmedicaredrugs.com		0	3			0					3	0	0		www.wpsmedicaredrugs.com	www.wpsmedicaredrugs.com
S5975	801	0	2021	29	Moda Health Rx (PDP)	National		National	1	3	1	PO Box 40327	Attn:  PERS Moda Health Rx (PDP)	Portland	OR	97240		PharmacyMedicare@modahealth.com	PharmacyMedicare@modahealth.com									5000000000207002000307002000407002000507002000607002000000000000	5107002000207002000307002000407002000507002000607002000707002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.modahealth.com/medicare		0	3			0					3	0	0		www.modahealth.com/medicare	www.modahealth.com/medicare
S0655	801	0	2021	29	Tufts Medicare Preferred PDP Group (PDP)	Massachusetts and Nationwide		Massachusetts and Nationwide	1	3	1	705 Mt Auburn Street		Watertown	MA	02472		Joseph_zaza@tufts-health.com	Annette_DiFelice@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/plans/employer-plans		0	3			0					3	0	0		https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
S0655	802	0	2021	29	Tufts Medicare Preferred PDP Group (PDP)	Massachusetts and Nationwide		Massachusetts and Nationwide	1	3	1	705 Mt Auburn Street		Watertown	MA	02472		Joseph_Joyce@tufts-health.com	Annette_DiFelice@tufts-health.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	tuftsmedicarepreferred.org/plans/employer-plans		0	3			0					3	0	0		https://www.tuftsmedicarepreferred.org/tufts-health-plan-doctor-search	tuftsmedicarepreferred.org/drug-coverage
S5857	802	0	2021	29	PriorityMedicare Rx EG Non-Calendar Year (PDP)	United States		United States	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com		0	3			0					3	0	0		www.prioritymedicare.com	www.prioritymedicare.com
S5857	803	0	2021	29	PriorityMedicare Rx EG Calendar Year (PDP)	United States		United States	1	3	1	1231 East Beltline NE		Grand Rapids	MI	49525												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.prioritymedicare.com		0	3			0					3	0	0		www.prioritymedicare.com	www.prioritymedicare.com
S3994	801	0	2021	29	Medicare Rx EGWP CY (PDP)	National		National	1	3	1	AMS	P.O. Box 860	Honolulu	HI	96808												7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com		0	3			0					3	0	0		www.hmsa.com	www.hmsa.com
S3994	802	0	2021	29	Medicare Rx EGWP NCY (PDP)	National		National	1	3	1	AMS	P.O. Box 860	Honolulu	HI	96808												7000000000208002000308002000408002000508002000608002000000000000	7108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hmsa.com		0	3			0					3	0	0		www.hmsa.com	www.hmsa.com
S5884	101	0	2021	29	Humana Basic Rx Plan (PDP)	States of Maine and New Hampshire		States of Maine and New Hampshire	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	102	0	2021	29	Humana Basic Rx Plan (PDP)	States of CT, MA, RI, VT		States of CT, MA, RI, VT	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	103	0	2021	29	Humana Basic Rx Plan (PDP)	States of DC, DE, MD		States of DC, DE, MD	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	104	0	2021	29	Humana Basic Rx Plan (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	105	0	2021	29	Humana Basic Rx Plan (PDP)	State of Florida		State of Florida	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					1	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	106	0	2021	29	Humana Basic Rx Plan (PDP)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	107	0	2021	29	Humana Basic Rx Plan (PDP)	State of Illinois		State of Illinois	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	108	0	2021	29	Humana Basic Rx Plan (PDP)	State of Louisiana		State of Louisiana	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					1	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	109	0	2021	29	Humana Basic Rx Plan (PDP)	State of Kansas		State of Kansas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	110	0	2021	29	Humana Basic Rx Plan (PDP)	State of New Mexico		State of New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	111	0	2021	29	Humana Basic Rx Plan (PDP)	State of Colorado		State of Colorado	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	112	0	2021	29	Humana Basic Rx Plan (PDP)	State of Nevada		State of Nevada	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	113	0	2021	29	Humana Basic Rx Plan (PDP)	States of Oregon and Washington		States of Oregon and Washington	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	114	0	2021	29	Humana Basic Rx Plan (PDP)	State of California		State of California	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	115	0	2021	29	Humana Basic Rx Plan (PDP)	State of Hawaii		State of Hawaii	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	116	0	2021	29	Humana Basic Rx Plan (PDP)	State of Alaska		State of Alaska	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	131	0	2021	29	Humana Basic Rx Plan (PDP)	State of New Jersey		State of New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	132	0	2021	29	Humana Basic Rx Plan (PDP)	State of Virginia		State of Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					1	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	133	0	2021	29	Humana Basic Rx Plan (PDP)	State of North Carolina		State of North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	134	0	2021	29	Humana Basic Rx Plan (PDP)	State of South Carolina		State of South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	135	0	2021	29	Humana Basic Rx Plan (PDP)	State of Georgia		State of Georgia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	136	0	2021	29	Humana Basic Rx Plan (PDP)	State of Michigan		State of Michigan	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	137	0	2021	29	Humana Basic Rx Plan (PDP)	State of Ohio		State of Ohio	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	138	0	2021	29	Humana Basic Rx Plan (PDP)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	139	0	2021	29	Humana Basic Rx Plan (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	140	0	2021	29	Humana Basic Rx Plan (PDP)	State of Missouri		State of Missouri	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	141	0	2021	29	Humana Basic Rx Plan (PDP)	State of Arkansas		State of Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	142	0	2021	29	Humana Basic Rx Plan (PDP)	State of Mississippi		State of Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	143	0	2021	29	Humana Basic Rx Plan (PDP)	State of Texas		State of Texas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	144	0	2021	29	Humana Basic Rx Plan (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	145	0	2021	29	Humana Basic Rx Plan (PDP)	States of IA, MN, MT, ND, NE, SD, WY		States of IA, MN, MT, ND, NE, SD, WY	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					1	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	146	0	2021	29	Humana Basic Rx Plan (PDP)	State of Arizona		State of Arizona	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					1	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	147	0	2021	29	Humana Basic Rx Plan (PDP)	States of Idaho and Utah		States of Idaho and Utah	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	148	0	2021	29	Humana Premier Rx Plan (PDP)	States of Maine and New Hampshire		States of Maine and New Hampshire	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	149	0	2021	29	Humana Premier Rx Plan (PDP)	States of CT, MA, RI, VT		States of CT, MA, RI, VT	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	150	0	2021	29	Humana Premier Rx Plan (PDP)	State of New Jersey		State of New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	151	0	2021	29	Humana Premier Rx Plan (PDP)	States of DC, DE, MD		States of DC, DE, MD	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	152	0	2021	29	Humana Premier Rx Plan (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	153	0	2021	29	Humana Premier Rx Plan (PDP)	State of Virginia		State of Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	154	0	2021	29	Humana Premier Rx Plan (PDP)	State of North Carolina		State of North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	155	0	2021	29	Humana Premier Rx Plan (PDP)	State of South Carolina		State of South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	156	0	2021	29	Humana Premier Rx Plan (PDP)	State of Georgia		State of Georgia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	157	0	2021	29	Humana Premier Rx Plan (PDP)	State of Florida		State of Florida	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	158	0	2021	29	Humana Premier Rx Plan (PDP)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	159	0	2021	29	Humana Premier Rx Plan (PDP)	State of Michigan		State of Michigan	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	160	0	2021	29	Humana Premier Rx Plan (PDP)	State of Ohio		State of Ohio	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	161	0	2021	29	Humana Premier Rx Plan (PDP)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	162	0	2021	29	Humana Premier Rx Plan (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	163	0	2021	29	Humana Premier Rx Plan (PDP)	State of Illinois		State of Illinois	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	164	0	2021	29	Humana Premier Rx Plan (PDP)	State of Missouri		State of Missouri	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	165	0	2021	29	Humana Premier Rx Plan (PDP)	State of Arkansas		State of Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	166	0	2021	29	Humana Premier Rx Plan (PDP)	State of Mississippi		State of Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	167	0	2021	29	Humana Premier Rx Plan (PDP)	State of Louisiana		State of Louisiana	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	168	0	2021	29	Humana Premier Rx Plan (PDP)	State of Texas		State of Texas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	169	0	2021	29	Humana Premier Rx Plan (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	170	0	2021	29	Humana Premier Rx Plan (PDP)	State of Kansas		State of Kansas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	171	0	2021	29	Humana Premier Rx Plan (PDP)	States of IA, MN, MT, ND, NE, SD, WY		States of IA, MN, MT, ND, NE, SD, WY	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	172	0	2021	29	Humana Premier Rx Plan (PDP)	State of New Mexico		State of New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	173	0	2021	29	Humana Premier Rx Plan (PDP)	State of Colorado		State of Colorado	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	174	0	2021	29	Humana Premier Rx Plan (PDP)	State of Arizona		State of Arizona	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	175	0	2021	29	Humana Premier Rx Plan (PDP)	State of Nevada		State of Nevada	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	176	0	2021	29	Humana Premier Rx Plan (PDP)	States of Oregon and Washington		States of Oregon and Washington	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	177	0	2021	29	Humana Premier Rx Plan (PDP)	States of Idaho and Utah		States of Idaho and Utah	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	178	0	2021	29	Humana Premier Rx Plan (PDP)	State of California		State of California	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	179	0	2021	29	Humana Premier Rx Plan (PDP)	State of Hawaii		State of Hawaii	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	180	0	2021	29	Humana Premier Rx Plan (PDP)	State of Alaska		State of Alaska	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	181	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of Maine and New Hampshire		States of Maine and New Hampshire	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	182	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of CT, MA, RI, VT		States of CT, MA, RI, VT	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	183	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of New Jersey		State of New Jersey	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	184	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of DC, DE, MD		States of DC, DE, MD	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	185	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	186	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Virginia		State of Virginia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	187	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of North Carolina		State of North Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	188	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of South Carolina		State of South Carolina	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	189	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Georgia		State of Georgia	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	190	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Florida		State of Florida	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	191	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	192	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Michigan		State of Michigan	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	193	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Ohio		State of Ohio	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	194	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	195	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	196	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Illinois		State of Illinois	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	197	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Missouri		State of Missouri	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	198	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Arkansas		State of Arkansas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	199	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Mississippi		State of Mississippi	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	200	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Louisiana		State of Louisiana	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	201	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Texas		State of Texas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	202	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	203	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Kansas		State of Kansas	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	204	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of IA, MN, MT, ND, NE, SD, WY		States of IA, MN, MT, ND, NE, SD, WY	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	205	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of New Mexico		State of New Mexico	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	206	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Colorado		State of Colorado	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	207	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Arizona		State of Arizona	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	208	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Nevada		State of Nevada	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	209	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of Oregon and Washington		States of Oregon and Washington	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	210	0	2021	29	Humana Walmart Value Rx Plan (PDP)	States of Idaho and Utah		States of Idaho and Utah	1	0	0	500 West Main street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	211	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of California		State of California	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	212	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Hawaii		State of Hawaii	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	213	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of Alaska		State of Alaska	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5884	834	0	2021	29	Humana Medicare Employer (PDP)	All Regions		All Regions	1	3	1	500 West Main Street		Louisville	KY	40202												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5993	001	0	2021	29	Horizon Medicare Blue Rx Standard (PDP)	New Jersey		New Jersey	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.horizonblue.com/Medicare		0	3			0					3	0	0		http://www.horizonblue.com/pdp-pharmacy-search	http://www.horizonblue.com/pdp-drug-search
S5993	003	0	2021	29	Horizon Medicare Blue Rx Enhanced (PDP)	New Jersey		New Jersey	1	0	0	3 Penn Plaza East, PP-09 W		Newark	NJ	07105												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.horizonblue.com/Medicare		0	3			0					3	0	0		http://www.horizonblue.com/pdp-pharmacy-search	http://www.horizonblue.com/pdp-drug-search
S5993	007	0	2021	29	Horizon Medicare Blue Rx Saver (PDP)	New Jersey		New Jersey	1	0	0	3 Penn Plaza East, PP-12F		Newark	NJ	07105												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.horizonblue.com/Medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $150.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $150.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		http://www.horizonblue.com/pdp-pharmacy-search	http://www.horizonblue.com/pdp-drug-search
S5993	801	0	2021	29	Horizon Medicare Blue Group Rx (PDP)	National		National	1	3	1	3 Penn Plaza East, PP-09 W		Newark	NJ	07105												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com		0	3			0					3	0	0		https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPDPG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPDPG/en/find-medicine.html
S5993	804	0	2021	29	Horizon Medicare Blue Group Rx Plus (PDP)	National		National	1	3	1	3 Penn Plaza East, PP-09 W		Newark	NJ	07105												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com		0	3			0					3	0	0		https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPDPG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPDPG/en/find-medicine.html
S5993	805	0	2021	29	Horizon Medicare Blue Group Rx Value (PDP)	National		National	1	3	1	3 Penn Plaza East, PP-09 W		Newark	NJ	07105												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.HorizonBlue.com		0	3			0					3	0	0		https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPDPG/en.html	https://www.myprime.com/v/HBCBSNJ/MEDICARE_D/NJPDPG/en/find-medicine.html
S1894	001	0	2021	29	CommunityCare Prescription Drug Plan (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	Two W 2nd Street	Suite 100	Tulsa	OK	74103		ccare@ccok.com	ccare@ccok.com									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.ccokadvantage.com		0	3			0					3	0	0		www.ccokadvantage.com/2021/PDP/Pharmacy-and-Rx-Info.asp	www.medicareplanrx.com/jccf/ccok_pdp_formulary_21.html
S8067	001	0	2021	29	SecureRx - Option 3 (PDP)	Region 6 - Pennsylvania, West Virginia		Region 6 - Pennsylvania, West Virginia	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177			customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	003	0	2021	29	SecureRx - Option 1 (PDP)	Region 06 - Pennsylvania and West Virginia		Region 06 - Pennsylvania and West Virginia	1	0	0	2500 Elmerton Avenue		Harrisburg	PA	17177			customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	801	0	2021	29	SecureRx Group PDP Silver Rx (PDP)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177			customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	802	0	2021	29	SecureRx Group PDP Bronze Rx FY (PDP)	National		National	1	3	1	2500 Elmerton Avenue		Harrisburg	PA	17177			customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	803	0	2021	29	SecureRx Group PDP Gold Rx (PDP)	National		National	1	3	1	2500 Elmerton Avenue	Suite 201	Harrisburg	PA	17177		medicareadvantagehmo@capbluecross.com	customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	804	0	2021	29	SecureRx Group PDP Bronze Rx (PDP)	National		National	1	3	1	2500 Elmerton Avenue	Suite 201	Harrisburg	PA	17177		medicareadvantagehmo@capbluecross.com	customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	805	0	2021	29	SecureRx Group PDP Platinum Rx (PDP)	National		National	1	3	1	2500 Elmerton Avenue	Suite 201	Harrisburg	PA	17177		medicareadvantagehmo@capbluecross.com	customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	806	0	2021	29	SecureRx Group PDP Platinum Rx FY (PDP)	National		National	1	3	1	2500 Elmerton Avenue	Suite 201	Harrisburg	PA	17177		medicareadvantagehmo@capbluecross.com	customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	807	0	2021	29	SecureRx Group PDP Gold Rx FY (PDP)	National		National	1	3	1	2500 Elmerton Avenue	Suite 201	Harrisburg	PA	17177		medicareadvantagehmo@capbluecross.com	customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S8067	808	0	2021	29	SecureRx Group PDP Silver Rx FY (PDP)	National		National	1	3	1	2500 Elmerton Avenue	Suite 201	Harrisburg	PA	17177		medicareadvantagehmo@capbluecross.com	customerservice@securerxpdp.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.avalonsecurerxpdp.com		0	3			0					3	0	0		www.avalonsecurerxpdp.com	www.avalonsecurerxpdp.com
S5601	002	0	2021	29	SilverScript Choice (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $305.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $305.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	003	0	2021	29	SilverScript Plus (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	004	0	2021	29	SilverScript Choice (PDP)	Central New England (CT, MA, RI, VT)		Central New England (CT, MA, RI, VT)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $225.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $225.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	005	0	2021	29	SilverScript Plus (PDP)	Central New England (CT, MA, RI, VT)		Central New England (CT, MA, RI, VT)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	006	0	2021	29	SilverScript Choice (PDP)	New York		New York	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	007	0	2021	29	SilverScript Plus (PDP)	New York		New York	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	008	0	2021	29	SilverScript Choice (PDP)	New Jersey		New Jersey	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	009	0	2021	29	SilverScript Plus (PDP)	New Jersey		New Jersey	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	010	0	2021	29	SilverScript Choice (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	011	0	2021	29	SilverScript Plus (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	012	0	2021	29	SilverScript Choice (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	013	0	2021	29	SilverScript Plus (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	014	0	2021	29	SilverScript Choice (PDP)	Virginia		Virginia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $380.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $380.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	015	0	2021	29	SilverScript Plus (PDP)	Virginia		Virginia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	016	0	2021	29	SilverScript Choice (PDP)	North Carolina		North Carolina	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	017	0	2021	29	SilverScript Plus (PDP)	North Carolina		North Carolina	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	018	0	2021	29	SilverScript Choice (PDP)	South Carolina		South Carolina	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $355.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $355.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	019	0	2021	29	SilverScript Plus (PDP)	South Carolina		South Carolina	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	020	0	2021	29	SilverScript Choice (PDP)	Georgia		Georgia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $335.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $335.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	021	0	2021	29	SilverScript Plus (PDP)	Georgia		Georgia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	022	0	2021	29	SilverScript Choice (PDP)	Florida		Florida	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $305.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $305.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	023	0	2021	29	SilverScript Plus (PDP)	Florida		Florida	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	024	0	2021	29	SilverScript Choice (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	025	0	2021	29	SilverScript Plus (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	026	0	2021	29	SilverScript Choice (PDP)	Michigan		Michigan	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	027	0	2021	29	SilverScript Plus (PDP)	Michigan		Michigan	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	028	0	2021	29	SilverScript Choice (PDP)	Ohio		Ohio	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	029	0	2021	29	SilverScript Plus (PDP)	Ohio		Ohio	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	030	0	2021	29	SilverScript Choice (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	031	0	2021	29	SilverScript Plus (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	032	0	2021	29	SilverScript Choice (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $205.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $205.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	033	0	2021	29	SilverScript Plus (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	034	0	2021	29	SilverScript Choice (PDP)	Illinois		Illinois	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	035	0	2021	29	SilverScript Plus (PDP)	Illinois		Illinois	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	036	0	2021	29	SilverScript Choice (PDP)	Missouri		Missouri	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $245.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $245.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	037	0	2021	29	SilverScript Plus (PDP)	Missouri		Missouri	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	038	0	2021	29	SilverScript Choice (PDP)	Arkansas		Arkansas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $265.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $265.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	040	0	2021	29	SilverScript Choice (PDP)	Mississippi		Mississippi	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	041	0	2021	29	SilverScript Plus (PDP)	Mississippi		Mississippi	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	042	0	2021	29	SilverScript Choice (PDP)	Louisiana		Louisiana	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $215.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $215.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	044	0	2021	29	SilverScript Choice (PDP)	Texas		Texas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $405.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $405.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	045	0	2021	29	SilverScript Plus (PDP)	Texas		Texas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	046	0	2021	29	SilverScript Choice (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $235.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $235.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	048	0	2021	29	SilverScript Choice (PDP)	Kansas		Kansas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	049	0	2021	29	SilverScript Plus (PDP)	Kansas		Kansas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	050	0	2021	29	SilverScript Choice (PDP)	Upper MW and N.Plains (IA, MN, MT, ND, NE, SD, WY)		Upper MW and N.Plains (IA, MN, MT, ND, NE, SD, WY)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	051	0	2021	29	SilverScript Plus (PDP)	Upper MW and N.Plains (IA, MN, MT, ND, NE, SD, WY)		Upper MW and N.Plains (IA, MN, MT, ND, NE, SD, WY)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	052	0	2021	29	SilverScript Choice (PDP)	New Mexico		New Mexico	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $320.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $320.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	053	0	2021	29	SilverScript Plus (PDP)	New Mexico		New Mexico	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	054	0	2021	29	SilverScript Choice (PDP)	Colorado		Colorado	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $370.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $370.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	055	0	2021	29	SilverScript Plus (PDP)	Colorado		Colorado	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	056	0	2021	29	SilverScript Choice (PDP)	Arizona		Arizona	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	057	0	2021	29	SilverScript Plus (PDP)	Arizona		Arizona	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	058	0	2021	29	SilverScript Choice (PDP)	Nevada		Nevada	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	059	0	2021	29	SilverScript Plus (PDP)	Nevada		Nevada	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	060	0	2021	29	SilverScript Choice (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $260.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $260.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	061	0	2021	29	SilverScript Plus (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	062	0	2021	29	SilverScript Choice (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	063	0	2021	29	SilverScript Plus (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	064	0	2021	29	SilverScript Choice (PDP)	California		California	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $250.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $250.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	065	0	2021	29	SilverScript Plus (PDP)	California		California	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	066	0	2021	29	SilverScript Choice (PDP)	Hawaii		Hawaii	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	067	0	2021	29	SilverScript Plus (PDP)	Hawaii		Hawaii	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	068	0	2021	29	SilverScript Choice (PDP)	Alaska		Alaska	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $230.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $230.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	107	0	2021	29	SilverScript Plus (PDP)	Arkansas		Arkansas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	108	0	2021	29	SilverScript Plus (PDP)	Louisiana		Louisiana	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	109	0	2021	29	SilverScript Plus (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	176	0	2021	29	SilverScript SmartRx (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	177	0	2021	29	SilverScript SmartRx (PDP)	Central New England (CT, MA, RI, VT)		Central New England (CT, MA, RI, VT)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	178	0	2021	29	SilverScript SmartRx (PDP)	New York		New York	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	179	0	2021	29	SilverScript SmartRx (PDP)	New Jersey		New Jersey	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	180	0	2021	29	SilverScript SmartRx (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	181	0	2021	29	SilverScript SmartRx (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	182	0	2021	29	SilverScript SmartRx (PDP)	Virginia		Virginia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	183	0	2021	29	SilverScript SmartRx (PDP)	North Carolina		North Carolina	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	184	0	2021	29	SilverScript SmartRx (PDP)	South Carolina		South Carolina	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	185	0	2021	29	SilverScript SmartRx (PDP)	Georgia		Georgia	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	186	0	2021	29	SilverScript SmartRx (PDP)	Florida		Florida	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	187	0	2021	29	SilverScript SmartRx (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	188	0	2021	29	SilverScript SmartRx (PDP)	Michigan		Michigan	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	189	0	2021	29	SilverScript SmartRx (PDP)	Ohio		Ohio	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	190	0	2021	29	SilverScript SmartRx (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	191	0	2021	29	SilverScript SmartRx (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	192	0	2021	29	SilverScript SmartRx (PDP)	Illinois		Illinois	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	193	0	2021	29	SilverScript SmartRx (PDP)	Missouri		Missouri	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	194	0	2021	29	SilverScript SmartRx (PDP)	Arkansas		Arkansas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	195	0	2021	29	SilverScript SmartRx (PDP)	Mississippi		Mississippi	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	196	0	2021	29	SilverScript SmartRx (PDP)	Louisiana		Louisiana	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	197	0	2021	29	SilverScript SmartRx (PDP)	Texas		Texas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	198	0	2021	29	SilverScript SmartRx (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	199	0	2021	29	SilverScript SmartRx (PDP)	Kansas		Kansas	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	200	0	2021	29	SilverScript SmartRx (PDP)	Upper MW and N.Plains (IA, MN, MT, ND, NE, SD, WY)		Upper MW and N.Plains (IA, MN, MT, ND, NE, SD, WY)	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	201	0	2021	29	SilverScript SmartRx (PDP)	New Mexico		New Mexico	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	202	0	2021	29	SilverScript SmartRx (PDP)	Colorado		Colorado	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	203	0	2021	29	SilverScript SmartRx (PDP)	Arizona		Arizona	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	204	0	2021	29	SilverScript SmartRx (PDP)	Nevada		Nevada	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	205	0	2021	29	SilverScript SmartRx (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	206	0	2021	29	SilverScript SmartRx (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	207	0	2021	29	SilverScript SmartRx (PDP)	California		California	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	208	0	2021	29	SilverScript SmartRx (PDP)	Hawaii		Hawaii	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	209	0	2021	29	SilverScript SmartRx (PDP)	Alaska		Alaska	1	0	0	P.O. Box 30016		Pittsburgh	PA	15222												9100000000200000000300000000400000000500000000600000000700000000	9100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.aetnamedicare.com	www.aetnamedicare.com
S5601	801	0	2021	29	SilverScript Group (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	802	0	2021	29	SilverScript Group (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	803	0	2021	29	SilverScript Group FI AET (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	804	0	2021	29	SilverScript Group FI (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	805	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	806	0	2021	29	SilverScript Group SF AET (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	807	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	808	0	2021	29	SilverScript Group SF - Non Calendar (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	809	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	810	0	2021	29	SilverScript Group SF - Non Calendar (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	811	0	2021	29	SilverScript Group - State of NY (PDP)	National		National	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	812	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	813	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	814	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	815	0	2021	29	SilverScript Group SF (PDP)	National SilverScript Group		National SilverScript Group	1	3	1	P.O. Box 53991		Phoenix	AZ	85072												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	816	0	2021	29	Aetna Medicare Rx offered by SilverScript - FI (PDP)	Employer National		Employer National	1	3	1	PO Box 30007		Pittsburgh	PA	15222												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	818	0	2021	29	Aetna Medicare Rx offered by SilverScript - SF (PDP)	Employer National		Employer National	1	3	1	PO Box 30007		Pittsburgh	PA	15222												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S5601	820	0	2021	29	Aetna Medicare Rx offered by SilverScript - DC (PDP)	Employer National		Employer National	1	3	1	PO Box 30007		Pittsburgh	PA	15222												4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.aetnamedicare.com		0	3			0					3	0	0		www.aetnamedicare.com/findpharmacy	http://www.aetnamedicare.com/formulary
S1140	801	0	2021	29	Group PDP (PDP)	New York State		New York State	1	3	1	PO Box 80		Buffalo	NY	14202			customerservice@bcbswny.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nymedicare.com		0	3			0					3	0	0		www.nymedicare.com	www.nymedicare.com
S1140	802	0	2021	29	Group PDP Enhanced (PDP)	New York State		New York State	1	3	1	PO Box 80		Buffalo	NY	14202												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.nymedicare.com		0	3			0					3	0	0		www.nymedicare.com	www.nymedicare.com
S5743	001	0	2021	29	MedicareBlue Rx Standard (PDP)	States of IA, MN, MT, NE, ND, SD, WY		States of IA, MN, MT, NE, ND, SD, WY	1	0	0	MedicareBlue Rx	4301 Cambridge Road	Fort Worth	TX	76155												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.YourMedicareSolutions.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		www.YourMedicareSolutions.com	www.YourMedicareSolutions.com
S5743	004	0	2021	29	MedicareBlue Rx Premier (PDP)	States of IA, MN, MT, NE, ND, SD, WY		States of IA, MN, MT, NE, ND, SD, WY	1	0	0	MedicareBlue Rx	4301 Cambridge Road	Fort Worth	TX	76155												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourMedicareSolutions.com		0	3			0					2	0	0		www.YourMedicareSolutions.com	www.YourMedicareSolutions.com
S5743	802	0	2021	29	Group MedicareBlue Rx (PDP)	Nationwide		Nationwide	1	3	1	MedicareBlue Rx Group	4301 Cambridge Road	Fort Worth	TX	76155												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.YourMedicareSolutions.com		0	3			0					3	0	0		www.YourMedicareSolutions.com	www.YourMedicareSolutions.com
S5743	805	0	2021	29	Group MedicareBlue Rx Self-funded (PDP)	Nationwide		Nationwide	1	3	1	MedicareBlue Rx Group	4301 Cambridge Road	Fort Worth	TX	76155												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.YourMedicareSolutions.com		0	3			0					3	0	0		www.YourMedicareSolutions.com	www.YourMedicareSolutions.com
S6875	801	0	2021	29	Select Option Rx Group Option I CY (PDP)	National		National	1	3	1	PO Box 41514		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.ibxmedicare.com		0	3			0					3	0	0		http://www.ibxmedicare.com	http://www.ibxmedicare.com
S6875	802	0	2021	29	Select Option Rx Group Option I Non-CY (PDP)	National		National	1	3	1	PO Box 41514		Philadelphia	PA	19101												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.ibxmedicare.com		0	3			0					3	0	0		http://www.ibxmedicare.com	http://www.ibxmedicare.com
S5953	001	0	2021	29	BlueCross Rx Value (PDP)	South Carolina		South Carolina	1	0	0	PO Box 100191		Columbia	SC	29223		Laurin.Boggero@BCBSSC.com	Laurin.Boggero@BCBSSC.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
S5953	002	0	2021	29	BlueCross Rx Plus (PDP)	South Carolina		South Carolina	1	0	0	PO Box 100191		Columbia	SC	29223		Laurin.Boggero@BCBSSC.com	Laurin.Boggero@BCBSSC.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com/marx21		0	3			0					3	0	0		www.scbluesmedadvantage.com/marx21	www.scbluesmedadvantage.com/marx21
S5953	801	0	2021	29	Group Blue Rx Plus (PDP)	South Carolina		South Carolina	1	3	1	PO Box 100191		Columbia	SC	29223		Laurin.Boggero@BCBSSC.com	Laurin.Boggero@BCBSSC.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com		0	3			0					3	0	0		www.scbluesmedadvantage.com	www.scbluesmedadvantage.com
S5953	802	0	2021	29	Group Blue Rx Plus (PDP)	South Carolina		South Carolina	1	3	1	PO Box 100191		Columbia	SC	29223		Laurin.Boggero@BCBSSC.com	Laurin.Boggero@BCBSSC.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.scbluesmedadvantage.com		0	3			0					3	0	0		www.scbluesmedadvantage.com	www.scbluesmedadvantage.com
S5768	125	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	126	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Central New England  (CT, RI, MA, VT)		Central New England  (CT, RI, MA, VT)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	127	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	New Jersey		New Jersey	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	128	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	129	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	130	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Virginia		Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	131	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	North Carolina		North Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	132	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	South Carolina		South Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	133	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Georgia		Georgia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	134	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Florida		Florida	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	135	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	136	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Michigan		Michigan	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	137	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Ohio		Ohio	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	138	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	139	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Wisconsin		Wisconsin	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	140	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Illinois		Illinois	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	141	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Missouri		Missouri	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	142	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Arkansas		Arkansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	143	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Mississippi		Mississippi	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	144	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Louisiana		Louisiana	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	145	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Texas		Texas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	146	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Oklahoma		Oklahoma	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	147	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Kansas		Kansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	148	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Upper MW and N Plains (IA, MN, NE, SD, ND, WY, MT)		Upper MW and N Plains (IA, MN, NE, SD, ND, WY, MT)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	149	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	New Mexico		New Mexico	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	150	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Colorado		Colorado	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	151	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Arizona		Arizona	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	152	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Nevada		Nevada	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	153	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	154	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	155	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	California		California	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	197	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Alaska		Alaska	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	198	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	Hawaii		Hawaii	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5768	200	0	2021	29	WellCare Medicare Rx Value Plus (PDP)	New York		New York	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5660	226	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Georgia	Express Scripts Medicare - Saver (PDP)	State of Georgia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	227	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Florida	Express Scripts Medicare - Saver (PDP)	State of Florida	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	228	0	2021	29	Express Scripts Medicare - Saver (PDP)	States of Alabama and Tennessee	Express Scripts Medicare - Saver (PDP)	States of Alabama and Tennessee	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	229	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Michigan	Express Scripts Medicare - Saver (PDP)	State of Michigan	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	230	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Ohio	Express Scripts Medicare - Saver (PDP)	State of Ohio	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	231	0	2021	29	Express Scripts Medicare - Saver (PDP)	States of Indiana and Kentucky	Express Scripts Medicare - Saver (PDP)	States of Indiana and Kentucky	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	232	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Wisconsin	Express Scripts Medicare - Saver (PDP)	State of Wisconsin	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	233	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Illinois	Express Scripts Medicare - Saver (PDP)	State of Illinois	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	234	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Missouri	Express Scripts Medicare - Saver (PDP)	State of Missouri	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	235	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Arkansas	Express Scripts Medicare - Saver (PDP)	State of Arkansas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	236	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Mississippi	Express Scripts Medicare - Saver (PDP)	State of Mississippi	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	237	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Louisiana	Express Scripts Medicare - Saver (PDP)	State of Louisiana	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	238	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Texas	Express Scripts Medicare - Saver (PDP)	State of Texas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	239	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Oklahoma	Express Scripts Medicare - Saver (PDP)	State of Oklahoma	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	240	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Kansas	Express Scripts Medicare - Saver (PDP)	State of Kansas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	241	0	2021	29	Express Scripts Medicare - Saver (PDP)	Upper Midwest and Northern Plains	Express Scripts Medicare - Saver (PDP)	Upper Midwest and Northern Plains	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	242	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of New Mexico	Express Scripts Medicare - Saver (PDP)	State of New Mexico	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	243	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Colorado	Express Scripts Medicare - Saver (PDP)	State of Colorado	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	244	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Arizona	Express Scripts Medicare - Saver (PDP)	State of Arizona	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	245	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Nevada	Express Scripts Medicare - Saver (PDP)	State of Nevada	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	246	0	2021	29	Express Scripts Medicare - Saver (PDP)	States of Oregon and Washington	Express Scripts Medicare - Saver (PDP)	States of Oregon and Washington	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	247	0	2021	29	Express Scripts Medicare - Saver (PDP)	States of Idaho and Utah	Express Scripts Medicare - Saver (PDP)	States of Idaho and Utah	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	248	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of California	Express Scripts Medicare - Saver (PDP)	State of California	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	249	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Hawaii	Express Scripts Medicare - Saver (PDP)	State of Hawaii	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	250	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Alaska	Express Scripts Medicare - Saver (PDP)	State of Alaska	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	251	0	2021	29	Express Scripts Medicare - Saver (PDP)	Puerto Rico	Express Scripts Medicare - Saver (PDP)	Puerto Rico	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	801	0	2021	29	Express Scripts Medicare (PDP)	Premier Access Open 5 Tier	Express Scripts Medicare (PDP)	Premier Access Open 5 Tier	1	3	1	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Express-ScriptsMedicare.com		0	3			0					3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	802	0	2021	29	Express Scripts Medicare (PDP)	Premier Performance Closed 5 Tier	Express Scripts Medicare (PDP)	Premier Performance Closed 5 Tier	1	3	1	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Express-ScriptsMedicare.com		0	3			0					3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	803	0	2021	29	Express Scripts Medicare (PDP)	High Performance Closed 5 Tier	Express Scripts Medicare (PDP)	High Performance Closed 5 Tier	1	3	1	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Express-ScriptsMedicare.com		0	3			0					3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	804	0	2021	29	Express Scripts Medicare (PDP)	Premier Performance Closed 5 - Non Calendar	Express Scripts Medicare (PDP)	Premier Performance Closed 5 - Non Calendar	1	3	1	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Express-ScriptsMedicare.com		0	3			0					3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	806	0	2021	29	Express Scripts Medicare (PDP)	National - URMBT 3 Tier	Express Scripts Medicare (PDP)	National - URMBT 3 Tier	1	3	1	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Express-ScriptsMedicare.com		0	3			0					3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	104	0	2021	29	Express Scripts Medicare - Value (PDP)	Northern New England	Express Scripts Medicare - Value (PDP)	Northern New England	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	105	0	2021	29	Express Scripts Medicare - Value (PDP)	Central New England	Express Scripts Medicare - Value (PDP)	Central New England	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	106	0	2021	29	Express Scripts Medicare - Value (PDP)	State of New Jersey	Express Scripts Medicare - Value (PDP)	State of New Jersey	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	107	0	2021	29	Express Scripts Medicare - Value (PDP)	Mid-Atlantic	Express Scripts Medicare - Value (PDP)	Mid-Atlantic	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	108	0	2021	29	Express Scripts Medicare - Value (PDP)	States of Pennsylvania and West Virginia	Express Scripts Medicare - Value (PDP)	States of Pennsylvania and West Virginia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	109	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Virginia	Express Scripts Medicare - Value (PDP)	State of Virginia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	110	0	2021	29	Express Scripts Medicare - Value (PDP)	State of North Carolina	Express Scripts Medicare - Value (PDP)	State of North Carolina	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	111	0	2021	29	Express Scripts Medicare - Value (PDP)	State of South Carolina	Express Scripts Medicare - Value (PDP)	State of South Carolina	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	112	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Georgia	Express Scripts Medicare - Value (PDP)	State of Georgia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	113	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Florida	Express Scripts Medicare - Value (PDP)	State of Florida	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	114	0	2021	29	Express Scripts Medicare - Value (PDP)	States of Alabama and Tennessee	Express Scripts Medicare - Value (PDP)	States of Alabama and Tennessee	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	115	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Michigan	Express Scripts Medicare - Value (PDP)	State of Michigan	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	116	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Ohio	Express Scripts Medicare - Value (PDP)	State of Ohio	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	117	0	2021	29	Express Scripts Medicare - Value (PDP)	States of Indiana and Kentucky	Express Scripts Medicare - Value (PDP)	States of Indiana and Kentucky	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	118	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Wisconsin	Express Scripts Medicare - Value (PDP)	State of Wisconsin	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	119	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Illinois	Express Scripts Medicare - Value (PDP)	State of Illinois	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	120	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Missouri	Express Scripts Medicare - Value (PDP)	State of Missouri	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	121	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Arkansas	Express Scripts Medicare - Value (PDP)	State of Arkansas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	122	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Mississippi	Express Scripts Medicare - Value (PDP)	State of Mississippi	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	123	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Louisiana	Express Scripts Medicare - Value (PDP)	State of Louisiana	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	124	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Texas	Express Scripts Medicare - Value (PDP)	State of Texas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	125	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Oklahoma	Express Scripts Medicare - Value (PDP)	State of Oklahoma	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	126	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Kansas	Express Scripts Medicare - Value (PDP)	State of Kansas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	127	0	2021	29	Express Scripts Medicare - Value (PDP)	Upper Midwest and Northern Plains	Express Scripts Medicare - Value (PDP)	Upper Midwest and Northern Plains	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	128	0	2021	29	Express Scripts Medicare - Value (PDP)	State of New Mexico	Express Scripts Medicare - Value (PDP)	State of New Mexico	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	129	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Colorado	Express Scripts Medicare - Value (PDP)	State of Colorado	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	130	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Arizona	Express Scripts Medicare - Value (PDP)	State of Arizona	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	131	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Nevada	Express Scripts Medicare - Value (PDP)	State of Nevada	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	132	0	2021	29	Express Scripts Medicare - Value (PDP)	States of Oregon and Washington	Express Scripts Medicare - Value (PDP)	States of Oregon and Washington	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	133	0	2021	29	Express Scripts Medicare - Value (PDP)	States of Idaho and Utah	Express Scripts Medicare - Value (PDP)	States of Idaho and Utah	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	134	0	2021	29	Express Scripts Medicare - Value (PDP)	State of California	Express Scripts Medicare - Value (PDP)	State of California	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	135	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Hawaii	Express Scripts Medicare - Value (PDP)	State of Hawaii	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	136	0	2021	29	Express Scripts Medicare - Value (PDP)	State of Alaska	Express Scripts Medicare - Value (PDP)	State of Alaska	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	137	0	2021	29	Express Scripts Medicare - Value (PDP)	Puerto Rico	Express Scripts Medicare - Value (PDP)	Puerto Rico	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	172	0	2021	29	Express Scripts Medicare - Choice (PDP)	Northern New England	Express Scripts Medicare - Choice (PDP)	Northern New England	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	176	0	2021	29	Express Scripts Medicare - Choice (PDP)	States of Pennsylvania and West Virginia	Express Scripts Medicare - Choice (PDP)	States of Pennsylvania and West Virginia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	180	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Georgia	Express Scripts Medicare - Choice (PDP)	State of Georgia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	181	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Florida	Express Scripts Medicare - Choice (PDP)	State of Florida	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	182	0	2021	29	Express Scripts Medicare - Choice (PDP)	States of Alabama and Tennessee	Express Scripts Medicare - Choice (PDP)	States of Alabama and Tennessee	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	183	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Michigan	Express Scripts Medicare - Choice (PDP)	State of Michigan	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	184	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Ohio	Express Scripts Medicare - Choice (PDP)	State of Ohio	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	185	0	2021	29	Express Scripts Medicare - Choice (PDP)	States of Indiana and Kentucky	Express Scripts Medicare - Choice (PDP)	States of Indiana and Kentucky	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	186	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Wisconsin	Express Scripts Medicare - Choice (PDP)	State of Wisconsin	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	187	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Illinois	Express Scripts Medicare - Choice (PDP)	State of Illinois	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	190	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Mississippi	Express Scripts Medicare - Choice (PDP)	State of Mississippi	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	192	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Texas	Express Scripts Medicare - Choice (PDP)	State of Texas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	194	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Kansas	Express Scripts Medicare - Choice (PDP)	State of Kansas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	195	0	2021	29	Express Scripts Medicare - Choice (PDP)	Upper Midwest and Northern Plains	Express Scripts Medicare - Choice (PDP)	Upper Midwest and Northern Plains	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	196	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of New Mexico	Express Scripts Medicare - Choice (PDP)	State of New Mexico	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	197	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Colorado	Express Scripts Medicare - Choice (PDP)	State of Colorado	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	198	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Arizona	Express Scripts Medicare - Choice (PDP)	State of Arizona	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	199	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Nevada	Express Scripts Medicare - Choice (PDP)	State of Nevada	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	202	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of California	Express Scripts Medicare - Choice (PDP)	State of California	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	203	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Hawaii	Express Scripts Medicare - Choice (PDP)	State of Hawaii	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	204	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Alaska	Express Scripts Medicare - Choice (PDP)	State of Alaska	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	206	0	2021	29	Express Scripts Medicare - Choice (PDP)	Central New England	Express Scripts Medicare - Choice (PDP)	Central New England	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	207	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of New Jersey	Express Scripts Medicare - Choice (PDP)	State of New Jersey	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	208	0	2021	29	Express Scripts Medicare - Choice (PDP)	Mid-Atlantic	Express Scripts Medicare - Choice (PDP)	Mid-Atlantic	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	209	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of North Carolina	Express Scripts Medicare - Choice (PDP)	State of North Carolina	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	210	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of South Carolina	Express Scripts Medicare - Choice (PDP)	State of South Carolina	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	211	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Missouri	Express Scripts Medicare - Choice (PDP)	State of Missouri	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	212	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Arkansas	Express Scripts Medicare - Choice (PDP)	State of Arkansas	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	213	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Louisiana	Express Scripts Medicare - Choice (PDP)	State of Louisiana	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	214	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Oklahoma	Express Scripts Medicare - Choice (PDP)	State of Oklahoma	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	215	0	2021	29	Express Scripts Medicare - Choice (PDP)	States of Oregon and Washington	Express Scripts Medicare - Choice (PDP)	States of Oregon and Washington	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	216	0	2021	29	Express Scripts Medicare - Choice (PDP)	States of Idaho and Utah	Express Scripts Medicare - Choice (PDP)	States of Idaho and Utah	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	217	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of Virginia	Express Scripts Medicare - Choice (PDP)	State of Virginia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	218	0	2021	29	Express Scripts Medicare - Saver (PDP)	Northern New England	Express Scripts Medicare - Saver (PDP)	Northern New England	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	219	0	2021	29	Express Scripts Medicare - Saver (PDP)	Central New England	Express Scripts Medicare - Saver (PDP)	Central New England	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	220	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of New Jersey	Express Scripts Medicare - Saver (PDP)	State of New Jersey	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	221	0	2021	29	Express Scripts Medicare - Saver (PDP)	Mid-Atlantic	Express Scripts Medicare - Saver (PDP)	Mid-Atlantic	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	222	0	2021	29	Express Scripts Medicare - Saver (PDP)	States of Pennsylvania and West Virginia	Express Scripts Medicare - Saver (PDP)	States of Pennsylvania and West Virginia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	223	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of Virginia	Express Scripts Medicare - Saver (PDP)	State of Virginia	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	224	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of North Carolina	Express Scripts Medicare - Saver (PDP)	State of North Carolina	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5660	225	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of South Carolina	Express Scripts Medicare - Saver (PDP)	State of South Carolina	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S2893	001	0	2021	29	Blue MedicareRx Value Plus (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	P.O. Box 30001		Pittsburgh	PA	15222												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.RxMedicarePlans.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.rxmedicareplans.com	www.rxmedicareplans.com
S2893	003	0	2021	29	Blue MedicareRx Premier (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	P.O. Box 30001		Pittsburgh	PA	15222												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.RxMedicarePlans.com		0	3			0					3	0	0		www.rxmedicareplans.com	www.rxmedicareplans.com
S2893	801	0	2021	29	Blue MedicareRx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	3	1	P.O. Box 30001		Pittsburgh	PA	15222												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Groups.RxMedicareplans.com		0	3			0					3	0	0		www.rxmedicareplans.com	www.rxmedicareplans.com
S2893	802	0	2021	29	Blue MedicareRx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	3	1	P.O. Box 30001		Pittsburgh	PA	15222												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	Groups.RxMedicareplans.com		0	3			0					3	0	0		www.rxmedicareplans.com	www.rxmedicareplans.com
E4744	801	0	2021	30	Missouri Department of Transportatio/ Highway Patr (Employer PDP)	National		National	1	3	1	105 W. Capitol Avenue		Jefferson City	MO	65102												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.modot.org/newsandinfo/GeneralInfo.htm		0	3			0					3	0	0		https://mp.medimpact.com/pharmacyportal/public/Login.jsp	http://www.modot.org/newsandinfo/GeneralInfo/documents/Formulary.htm
S5617	003	0	2021	29	Cigna Secure Rx (PDP)	New Hampshire and Maine	Cigna Secure Rx (PDP)	New Hampshire and Maine	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	008	0	2021	29	Cigna Secure Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont	Cigna Secure Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	013	0	2021	29	Cigna Secure Rx (PDP)	New York	Cigna Secure Rx (PDP)	New York	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	018	0	2021	29	Cigna Secure Rx (PDP)	New Jersey	Cigna Secure Rx (PDP)	New Jersey	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	053	0	2021	29	Cigna Secure Rx (PDP)	Florida	Cigna Secure Rx (PDP)	Florida	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	068	0	2021	29	Cigna Secure Rx (PDP)	Ohio	Cigna Secure Rx (PDP)	Ohio	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	088	0	2021	29	Cigna Secure Rx (PDP)	Missouri	Cigna Secure Rx (PDP)	Missouri	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	103	0	2021	29	Cigna Secure Rx (PDP)	Louisiana	Cigna Secure Rx (PDP)	Louisiana	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	108	0	2021	29	Cigna Secure Rx (PDP)	Texas	Cigna Secure Rx (PDP)	Texas	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	113	0	2021	29	Cigna Secure Rx (PDP)	Oklahoma	Cigna Secure Rx (PDP)	Oklahoma	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	118	0	2021	29	Cigna Secure Rx (PDP)	Kansas	Cigna Secure Rx (PDP)	Kansas	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	123	0	2021	29	Cigna Secure Rx (PDP)	IA, MN, MT, ND, NE, SD, WY	Cigna Secure Rx (PDP)	IA, MN, MT, ND, NE, SD, WY	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	128	0	2021	29	Cigna Secure Rx (PDP)	New Mexico	Cigna Secure Rx (PDP)	New Mexico	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	133	0	2021	29	Cigna Secure Rx (PDP)	Colorado	Cigna Secure Rx (PDP)	Colorado	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	138	0	2021	29	Cigna Secure Rx (PDP)	Arizona	Cigna Secure Rx (PDP)	Arizona	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	143	0	2021	29	Cigna Secure Rx (PDP)	Nevada	Cigna Secure Rx (PDP)	Nevada	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	148	0	2021	29	Cigna Secure Rx (PDP)	Oregon and Washington	Cigna Secure Rx (PDP)	Oregon and Washington	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	153	0	2021	29	Cigna Secure Rx (PDP)	Idaho and Utah	Cigna Secure Rx (PDP)	Idaho and Utah	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	158	0	2021	29	Cigna Secure Rx (PDP)	California	Cigna Secure Rx (PDP)	California	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	163	0	2021	29	Cigna Secure Rx (PDP)	Hawaii	Cigna Secure Rx (PDP)	Hawaii	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	214	0	2021	29	Cigna Secure Rx (PDP)	Delaware, District of Columbia and Maryland	Cigna Secure Rx (PDP)	Delaware, District of Columbia and Maryland	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	215	0	2021	29	Cigna Secure Rx (PDP)	Pennsylvania and West Virginia	Cigna Secure Rx (PDP)	Pennsylvania and West Virginia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	216	0	2021	29	Cigna Secure Rx (PDP)	Virginia	Cigna Secure Rx (PDP)	Virginia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	217	0	2021	29	Cigna Secure Rx (PDP)	North Carolina	Cigna Secure Rx (PDP)	North Carolina	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	218	0	2021	29	Cigna Secure Rx (PDP)	South Carolina	Cigna Secure Rx (PDP)	South Carolina	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	219	0	2021	29	Cigna Secure Rx (PDP)	Georgia	Cigna Secure Rx (PDP)	Georgia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	220	0	2021	29	Cigna Secure Rx (PDP)	Alabama and Tennessee	Cigna Secure Rx (PDP)	Alabama and Tennessee	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	221	0	2021	29	Cigna Secure Rx (PDP)	Michigan	Cigna Secure Rx (PDP)	Michigan	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	222	0	2021	29	Cigna Secure Rx (PDP)	Indiana and Kentucky	Cigna Secure Rx (PDP)	Indiana and Kentucky	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	223	0	2021	29	Cigna Secure Rx (PDP)	Wisconsin	Cigna Secure Rx (PDP)	Wisconsin	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	224	0	2021	29	Cigna Secure Rx (PDP)	Illinois	Cigna Secure Rx (PDP)	Illinois	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	225	0	2021	29	Cigna Secure Rx (PDP)	Arkansas	Cigna Secure Rx (PDP)	Arkansas	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	226	0	2021	29	Cigna Secure Rx (PDP)	Mississippi	Cigna Secure Rx (PDP)	Mississippi	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	227	0	2021	29	Cigna Secure Rx (PDP)	Alaska	Cigna Secure Rx (PDP)	Alaska	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	246	0	2021	29	Cigna Secure-Extra Rx (PDP)	New Hampshire and Maine	Cigna Secure-Extra Rx (PDP)	New Hampshire and Maine	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	247	0	2021	29	Cigna Secure-Extra Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont	Cigna Secure-Extra Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	248	0	2021	29	Cigna Secure-Extra Rx (PDP)	New York	Cigna Secure-Extra Rx (PDP)	New York	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	249	0	2021	29	Cigna Secure-Extra Rx (PDP)	New Jersey	Cigna Secure-Extra Rx (PDP)	New Jersey	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	250	0	2021	29	Cigna Secure-Extra Rx (PDP)	Delaware, Maryland and District of Columbia	Cigna Secure-Extra Rx (PDP)	Delaware, Maryland and District of Columbia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	251	0	2021	29	Cigna Secure-Extra Rx (PDP)	Pennsylvania and West Virginia	Cigna Secure-Extra Rx (PDP)	Pennsylvania and West Virginia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	252	0	2021	29	Cigna Secure-Extra Rx (PDP)	Virginia	Cigna Secure-Extra Rx (PDP)	Virginia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	253	0	2021	29	Cigna Secure-Extra Rx (PDP)	North Carolina	Cigna Secure-Extra Rx (PDP)	North Carolina	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	254	0	2021	29	Cigna Secure-Extra Rx (PDP)	South Carolina	Cigna Secure-Extra Rx (PDP)	South Carolina	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	255	0	2021	29	Cigna Secure-Extra Rx (PDP)	Georgia	Cigna Secure-Extra Rx (PDP)	Georgia	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	256	0	2021	29	Cigna Secure-Extra Rx (PDP)	Florida	Cigna Secure-Extra Rx (PDP)	Florida	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	257	0	2021	29	Cigna Secure-Extra Rx (PDP)	Alabama and Tennessee	Cigna Secure-Extra Rx (PDP)	Alabama and Tennessee	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	258	0	2021	29	Cigna Secure-Extra Rx (PDP)	Michigan	Cigna Secure-Extra Rx (PDP)	Michigan	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	259	0	2021	29	Cigna Secure-Extra Rx (PDP)	Ohio	Cigna Secure-Extra Rx (PDP)	Ohio	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	260	0	2021	29	Cigna Secure-Extra Rx (PDP)	Indiana and Kentucky	Cigna Secure-Extra Rx (PDP)	Indiana and Kentucky	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	261	0	2021	29	Cigna Secure-Extra Rx (PDP)	Wisconsin	Cigna Secure-Extra Rx (PDP)	Wisconsin	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	262	0	2021	29	Cigna Secure-Extra Rx (PDP)	Illinois	Cigna Secure-Extra Rx (PDP)	Illinois	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	263	0	2021	29	Cigna Secure-Extra Rx (PDP)	Missouri	Cigna Secure-Extra Rx (PDP)	Missouri	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	264	0	2021	29	Cigna Secure-Extra Rx (PDP)	Arkansas	Cigna Secure-Extra Rx (PDP)	Arkansas	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	265	0	2021	29	Cigna Secure-Extra Rx (PDP)	Mississippi	Cigna Secure-Extra Rx (PDP)	Mississippi	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	266	0	2021	29	Cigna Secure-Extra Rx (PDP)	Louisiana	Cigna Secure-Extra Rx (PDP)	Louisiana	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	267	0	2021	29	Cigna Secure-Extra Rx (PDP)	Texas	Cigna Secure-Extra Rx (PDP)	Texas	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	268	0	2021	29	Cigna Secure-Extra Rx (PDP)	Oklahoma	Cigna Secure-Extra Rx (PDP)	Oklahoma	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	269	0	2021	29	Cigna Secure-Extra Rx (PDP)	Kansas	Cigna Secure-Extra Rx (PDP)	Kansas	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	270	0	2021	29	Cigna Secure-Extra Rx (PDP)	IA, MN, MT, ND, NE, SD, WY	Cigna Secure-Extra Rx (PDP)	IA, MN, MT, ND, NE, SD, WY	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	271	0	2021	29	Cigna Secure-Extra Rx (PDP)	New Mexico	Cigna Secure-Extra Rx (PDP)	New Mexico	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	272	0	2021	29	Cigna Secure-Extra Rx (PDP)	Colorado	Cigna Secure-Extra Rx (PDP)	Colorado	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	273	0	2021	29	Cigna Secure-Extra Rx (PDP)	Arizona	Cigna Secure-Extra Rx (PDP)	Arizona	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	274	0	2021	29	Cigna Secure-Extra Rx (PDP)	Nevada	Cigna Secure-Extra Rx (PDP)	Nevada	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	275	0	2021	29	Cigna Secure-Extra Rx (PDP)	Oregon and Washington	Cigna Secure-Extra Rx (PDP)	Oregon and Washington	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	276	0	2021	29	Cigna Secure-Extra Rx (PDP)	Idaho and Utah	Cigna Secure-Extra Rx (PDP)	Idaho and Utah	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	277	0	2021	29	Cigna Secure-Extra Rx (PDP)	California	Cigna Secure-Extra Rx (PDP)	California	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	278	0	2021	29	Cigna Secure-Extra Rx (PDP)	Hawaii	Cigna Secure-Extra Rx (PDP)	Hawaii	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	279	0	2021	29	Cigna Secure-Extra Rx (PDP)	Alaska	Cigna Secure-Extra Rx (PDP)	Alaska	1	0	0	P O Box 269005		Weston	FL	33326												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	280	0	2021	29	Cigna Secure-Essential Rx (PDP)	New Hampshire and Maine	Cigna Secure-Essential Rx (PDP)	New Hampshire and Maine	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	281	0	2021	29	Cigna Secure-Essential Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont	Cigna Secure-Essential Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	282	0	2021	29	Cigna Secure-Essential Rx (PDP)	New York	Cigna Secure-Essential Rx (PDP)	New York	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	283	0	2021	29	Cigna Secure-Essential Rx (PDP)	New Jersey	Cigna Secure-Essential Rx (PDP)	New Jersey	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	284	0	2021	29	Cigna Secure-Essential Rx (PDP)	Delaware, District of Columbia and Maryland	Cigna Secure-Essential Rx (PDP)	Delaware, District of Columbia and Maryland	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	285	0	2021	29	Cigna Secure-Essential Rx (PDP)	Pennsylvania and West Virginia	Cigna Secure-Essential Rx (PDP)	Pennsylvania and West Virginia	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	286	0	2021	29	Cigna Secure-Essential Rx (PDP)	Virginia	Cigna Secure-Essential Rx (PDP)	Virginia	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	287	0	2021	29	Cigna Secure-Essential Rx (PDP)	North Carolina	Cigna Secure-Essential Rx (PDP)	North Carolina	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	288	0	2021	29	Cigna Secure-Essential Rx (PDP)	South Carolina	Cigna Secure-Essential Rx (PDP)	South Carolina	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	289	0	2021	29	Cigna Secure-Essential Rx (PDP)	Georgia	Cigna Secure-Essential Rx (PDP)	Georgia	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	290	0	2021	29	Cigna Secure-Essential Rx (PDP)	Florida	Cigna Secure-Essential Rx (PDP)	Florida	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	291	0	2021	29	Cigna Secure-Essential Rx (PDP)	Alabama and Tennessee	Cigna Secure-Essential Rx (PDP)	Alabama and Tennessee	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	292	0	2021	29	Cigna Secure-Essential Rx (PDP)	Michigan	Cigna Secure-Essential Rx (PDP)	Michigan	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	293	0	2021	29	Cigna Secure-Essential Rx (PDP)	Ohio	Cigna Secure-Essential Rx (PDP)	Ohio	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	294	0	2021	29	Cigna Secure-Essential Rx (PDP)	Indiana and Kentucky	Cigna Secure-Essential Rx (PDP)	Indiana and Kentucky	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	295	0	2021	29	Cigna Secure-Essential Rx (PDP)	Wisconsin	Cigna Secure-Essential Rx (PDP)	Wisconsin	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	296	0	2021	29	Cigna Secure-Essential Rx (PDP)	Illinois	Cigna Secure-Essential Rx (PDP)	Illinois	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	297	0	2021	29	Cigna Secure-Essential Rx (PDP)	Missouri	Cigna Secure-Essential Rx (PDP)	Missouri	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	298	0	2021	29	Cigna Secure-Essential Rx (PDP)	Arkansas	Cigna Secure-Essential Rx (PDP)	Arkansas	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	299	0	2021	29	Cigna Secure-Essential Rx (PDP)	Mississippi	Cigna Secure-Essential Rx (PDP)	Mississippi	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	300	0	2021	29	Cigna Secure-Essential Rx (PDP)	Louisiana	Cigna Secure-Essential Rx (PDP)	Louisiana	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	301	0	2021	29	Cigna Secure-Essential Rx (PDP)	Texas	Cigna Secure-Essential Rx (PDP)	Texas	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	302	0	2021	29	Cigna Secure-Essential Rx (PDP)	Oklahoma	Cigna Secure-Essential Rx (PDP)	Oklahoma	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	303	0	2021	29	Cigna Secure-Essential Rx (PDP)	Kansas	Cigna Secure-Essential Rx (PDP)	Kansas	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	304	0	2021	29	Cigna Secure-Essential Rx (PDP)	IA, MN, MT, ND, SD, NE, WY	Cigna Secure-Essential Rx (PDP)	IA, MN, MT, ND, SD, NE, WY	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	305	0	2021	29	Cigna Secure-Essential Rx (PDP)	New Mexico	Cigna Secure-Essential Rx (PDP)	New Mexico	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	306	0	2021	29	Cigna Secure-Essential Rx (PDP)	Colorado	Cigna Secure-Essential Rx (PDP)	Colorado	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	307	0	2021	29	Cigna Secure-Essential Rx (PDP)	Arizona	Cigna Secure-Essential Rx (PDP)	Arizona	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	308	0	2021	29	Cigna Secure-Essential Rx (PDP)	Nevada	Cigna Secure-Essential Rx (PDP)	Nevada	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	309	0	2021	29	Cigna Secure-Essential Rx (PDP)	Oregon and Washington	Cigna Secure-Essential Rx (PDP)	Oregon and Washington	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	310	0	2021	29	Cigna Secure-Essential Rx (PDP)	Idaho and Utah	Cigna Secure-Essential Rx (PDP)	Idaho and Utah	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	311	0	2021	29	Cigna Secure-Essential Rx (PDP)	California	Cigna Secure-Essential Rx (PDP)	California	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	312	0	2021	29	Cigna Secure-Essential Rx (PDP)	Hawaii	Cigna Secure-Essential Rx (PDP)	Hawaii	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	313	0	2021	29	Cigna Secure-Essential Rx (PDP)	Alaska	Cigna Secure-Essential Rx (PDP)	Alaska	1	0	0	P O Box 269005		Weston	FL	33326		LetUsHelpYou@HealthSpring.com	seniors@cigna.com									9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.cigna.com/part-d	www.cigna.com/part-d
S5617	801	0	2021	29	Cigna Rx Medicare (PDP)	Nationwide	Cigna Rx Medicare (PDP)	Nationwide	1	3	1	P O Box 42005		Phoenix	AZ	85080												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
S5617	802	0	2021	29	Cigna Rx Medicare FY (PDP)	Nationwide	Cigna Rx Medicare FY (PDP)	Nationwide	1	3	1	P O Box 42005		Phoenix	AZ	85080												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
S5617	805	0	2021	29	Cigna Rx Medicare (PDP)	Nationwide	Cigna Rx Medicare (PDP)	Nationwide	1	3	1	P O Box 42005		Phoenix	AZ	85080												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
S5617	806	0	2021	29	Cigna Rx Medicare FY (PDP)	Nationwide	Cigna Rx Medicare FY (PDP)	Nationwide	1	3	1	P O Box 42005		Phoenix	AZ	85080												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.cignamedicare.com		0	3			0					3	0	0		www.cigna.com/medicare	www.cignamedicare.com
S3285	801	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S3285	802	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S3285	803	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S3285	804	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S3285	805	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S3285	806	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S3285	807	0	2021	29	VibrantRx (PDP)	VibrantRx - National		VibrantRx - National	1	3	1	PO Box 509097		San Diego	CA	92150												5100000000200000000300000000400000000500000000600000000700000000	5100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.medimpact.com		0	3			0					3	0	0		https://www.medimpact.com	https://www.medimpact.com
S5795	002	0	2021	29	BlueMedicare Premier Rx (PDP)	State of Arkansas		State of Arkansas	1	0	0	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare		0	3			0					3	0	0		www.arkansasbluecross.com/medicare	http://www.arkansasbluecross.com/LookingForInsurance/MedicarePlans/default.aspx
S5795	003	0	2021	29	BlueMedicare Value Rx (PDP)	State of Arkansas		State of Arkansas	1	0	0	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.arkansasbluecross.com/medicare	http://www.arkansasbluecross.com/LookingForInsurance/MedicarePlans/default.aspx
S5795	008	0	2021	29	BlueMedicare Saver Rx (PDP)	State of Arkansas		State of Arkansas	1	0	0	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.arkansasbluecross.com/medicare	www.arkansasbluecross.com
S5795	804	0	2021	29	Arkansas BCBS Std Def Employer CY 4 (PDP)	Employer Group Plan		Employer Group Plan	1	3	1	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com		0	3			0					3	0	0		http://www.arkansasbluecross.com/medicare	http://www.arkansasbluecross.com/medicare
S5795	809	0	2021	29	Arkansas BCBS Std Def Employer NCY 4 (PDP)	Employer Group Plan		Employer Group Plan	1	3	1	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com		0	3			0					3	0	0		http://www.arkansasbluecross.com/medicare	http://www.arkansasbluecross.com/medicare
S5795	811	0	2021	29	ABCBS Group Basic CY (PDP)	Employer Group Plan		Employer Group Plan	1	3	1	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com		0	3			0					3	0	0		http://www.arkansasbluecross.com/medicare	http://www.arkansasbluecross.com/medicare
S5795	812	0	2021	29	ABCBS Group Basic PY (PDP)	Employer Group Plan		Employer Group Plan	1	3	1	P O Box 3648		Little Rock	AR	72203												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.arkansasbluecross.com		0	3			0					3	0	0		http://www.arkansasbluecross.com/medicare	http://www.arkansasbluecross.com/medicare
S5552	004	0	2021	29	Humana Basic Rx Plan (PDP)	State of New York		State of New York	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5552	005	0	2021	29	Humana Premier Rx Plan (PDP)	State of New York		State of New York	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5552	006	0	2021	29	Humana Walmart Value Rx Plan (PDP)	State of New York		State of New York	1	0	0	500 West Main Street		Louisville	KY	40202												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5552	801	0	2021	29	Humana Medicare Employer (PDP)	State of New York		State of New York	1	3	1	500 West Main Street		Louisville	KY	40202												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S3389	802	0	2021	29	UPMC Employer Group (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu									2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/		0	3			0					3	0	0		https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
S3389	803	0	2021	29	UPMC Employer Group (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	3	1	600 Grant Street		Pittsburgh	PA	15219		upmchp@msx.upmc.edu	upmchp@msx.upmc.edu									2000000000208002000308002000408002000508002000608002000708001500	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	http://www.upmchealthplan.com/medicare/		0	3			0					3	0	0		https://www.upmchealthplan.com/medicare/documents-and-forms/	https://www.upmchealthplan.com/medicare/documents-and-forms/
S3521	801	0	2021	29	Simply Prescriptions- Employer Group (PDP)	National and US Territories		National and US Territories	1	3	1	P.O. Box 211316		Eagan	MN	55121												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.SimplyPrescriptions.com		0	3			0					3	0	0		www.SimplyPrescriptions.com	www.SimplyPrescriptions.com
S3875	802	0	2021	29	Granite Alliance (PDP)	Granite Alliance National EGWP		Granite Alliance National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	803	0	2021	29	Granite Alliance Non-CY (PDP)	Granite Alliance Non-CY National EGWP		Granite Alliance Non-CY National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	804	0	2021	29	Granite Alliance (PDP)	Granite Alliance National EGWP		Granite Alliance National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	805	0	2021	29	Granite Alliance Non-CY (PDP)	Granite Alliance Non-CY National EGWP		Granite Alliance Non-CY National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	806	0	2021	29	Granite Alliance (PDP)	Granite Alliance National EGWP		Granite Alliance National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	807	0	2021	29	Granite Alliance Non-CY (PDP)	Granite Alliance Non-CY National EGWP		Granite Alliance Non-CY National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600001200700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	808	0	2021	29	Granite Alliance (PDP)	Granite Alliance National EGWP		Granite Alliance National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	809	0	2021	29	Granite Alliance Non-CY (PDP)	Granite Alliance Non-CY National EGWP		Granite Alliance Non-CY National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	810	0	2021	29	Granite Alliance (PDP)	Granite Alliance National EGWP		Granite Alliance National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S3875	811	0	2021	29	Granite Alliance Non-CY (PDP)	Granite Alliance Non-CY National EGWP		Granite Alliance Non-CY National EGWP	1	3	1	170 South Main Street	Suite 900	Salt Lake City	UT	84101		GAICHelp@magellanhealth.com	GAICHelp@magellanhealth.com									4100000000200000000300000000400000000500000000600000000700000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mygraniterx.com		0	3			0					3	0	0		www.mygraniterx.com	www.mygraniterx.com
S4219	801	0	2021	29	Health Alliance Group Medicare Prescription Plan (PDP)	United States		United States	1	3	1	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Healthalliancemedicare.org		0	3			0					3	0	0		www.Healthalliancemedicare.org	www.Healthalliancemedicare.org
S4219	802	0	2021	29	Medicare Employer PDP  - non calendar year (PDP)	United States		United States	1	3	1	3310 Fields South Drive		Champaign	IL	61822		MemberServices@healthalliance.org	MemberServices@healthalliance.org									3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Healthalliancemedicare.org		0	3			0					3	0	0		www.Healthalliancemedicare.org	www.Healthalliancemedicare.org
S8677	803	0	2021	29	Providence Medicare Part D Group Plan (PDP)	National		National	1	3	1	P.O. Box 4327		Portland	OR	97208		medicareinformationrequest@providence.org	phpcustomerservice@providence.org									5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.providencehealthassurance.com		0	3			0					3	0	0		www.providencehealthassurance.com	www.providencehealthassurance.com
S6946	001	0	2021	29	Clear Spring Health Value Rx (PDP)	New Jersey		New Jersey	1	0	0	P.O. BOX 4016		Scranton	PA	18505												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	002	0	2021	29	Clear Spring Health Value Rx (PDP)	D.C., Delaware, Maryland		D.C., Delaware, Maryland	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	003	0	2021	29	Clear Spring Health Value Rx (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	004	0	2021	29	Clear Spring Health Value Rx (PDP)	Virginia		Virginia	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	005	0	2021	29	Clear Spring Health Value Rx (PDP)	North Carolina		North Carolina	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	006	0	2021	29	Clear Spring Health Value Rx (PDP)	South Carolina		South Carolina	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	007	0	2021	29	Clear Spring Health Value Rx (PDP)	Georgia		Georgia	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	008	0	2021	29	Clear Spring Health Value Rx (PDP)	Florida		Florida	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	009	0	2021	29	Clear Spring Health Value Rx (PDP)	Alabama and Tennessee		Alabama and Tennessee	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	010	0	2021	29	Clear Spring Health Value Rx (PDP)	Michigan		Michigan	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	011	0	2021	29	Clear Spring Health Value Rx (PDP)	Ohio		Ohio	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	012	0	2021	29	Clear Spring Health Value Rx (PDP)	Kentucky and Indiana		Kentucky and Indiana	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	013	0	2021	29	Clear Spring Health Value Rx (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	014	0	2021	29	Clear Spring Health Value Rx (PDP)	Illinois		Illinois	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	015	0	2021	29	Clear Spring Health Value Rx (PDP)	Missouri		Missouri	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	016	0	2021	29	Clear Spring Health Value Rx (PDP)	Arkansas		Arkansas	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	017	0	2021	29	Clear Spring Health Value Rx (PDP)	Mississippi		Mississippi	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	018	0	2021	29	Clear Spring Health Value Rx (PDP)	Louisiana		Louisiana	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	019	0	2021	29	Clear Spring Health Value Rx (PDP)	Texas		Texas	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	020	0	2021	29	Clear Spring Health Value Rx (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	021	0	2021	29	Clear Spring Health Value Rx (PDP)	Kansas		Kansas	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	022	0	2021	29	Clear Spring Health Value Rx (PDP)	IA, MT, MN, NE, ND, SD, WY		IA, MT, MN, NE, ND, SD, WY	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	023	0	2021	29	Clear Spring Health Value Rx (PDP)	Arizona		Arizona	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	024	0	2021	29	Clear Spring Health Value Rx (PDP)	Nevada		Nevada	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	025	0	2021	29	Clear Spring Health Value Rx (PDP)	Oregon and Washington		Oregon and Washington	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	026	0	2021	29	Clear Spring Health Value Rx (PDP)	Idaho and Utah		Idaho and Utah	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	027	0	2021	29	Clear Spring Health Value Rx (PDP)	California		California	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	028	0	2021	29	Clear Spring Health Value Rx (PDP)	Hawaii		Hawaii	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	029	0	2021	29	Clear Spring Health Value Rx (PDP)	Alaska		Alaska	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0					3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	030	0	2021	29	Clear Spring Health Premier Rx (PDP)	New Jersey		New Jersey	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	031	0	2021	29	Clear Spring Health Premier Rx (PDP)	D.C., Delaware, Maryland		D.C., Delaware, Maryland	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	032	0	2021	29	Clear Spring Health Premier Rx (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	033	0	2021	29	Clear Spring Health Premier Rx (PDP)	Virginia		Virginia	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	034	0	2021	29	Clear Spring Health Premier Rx (PDP)	North Carolina		North Carolina	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	035	0	2021	29	Clear Spring Health Premier Rx (PDP)	South Carolina		South Carolina	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	036	0	2021	29	Clear Spring Health Premier Rx (PDP)	Georgia		Georgia	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	037	0	2021	29	Clear Spring Health Premier Rx (PDP)	Florida		Florida	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	038	0	2021	29	Clear Spring Health Premier Rx (PDP)	Alabama and Tennessee		Alabama and Tennessee	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	039	0	2021	29	Clear Spring Health Premier Rx (PDP)	Michigan		Michigan	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	040	0	2021	29	Clear Spring Health Premier Rx (PDP)	Ohio		Ohio	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	041	0	2021	29	Clear Spring Health Premier Rx (PDP)	Kentucky and Indiana		Kentucky and Indiana	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	042	0	2021	29	Clear Spring Health Premier Rx (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	043	0	2021	29	Clear Spring Health Premier Rx (PDP)	Illinois		Illinois	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	044	0	2021	29	Clear Spring Health Premier Rx (PDP)	Missouri		Missouri	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	045	0	2021	29	Clear Spring Health Premier Rx (PDP)	Arkansas		Arkansas	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	046	0	2021	29	Clear Spring Health Premier Rx (PDP)	Mississippi		Mississippi	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	047	0	2021	29	Clear Spring Health Premier Rx (PDP)	Louisiana		Louisiana	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	048	0	2021	29	Clear Spring Health Premier Rx (PDP)	Texas		Texas	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	049	0	2021	29	Clear Spring Health Premier Rx (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	050	0	2021	29	Clear Spring Health Premier Rx (PDP)	Kansas		Kansas	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	051	0	2021	29	Clear Spring Health Premier Rx (PDP)	IA, MT, MN, NE, ND, SD, WY		IA, MT, MN, NE, ND, SD, WY	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	052	0	2021	29	Clear Spring Health Premier Rx (PDP)	Arizona		Arizona	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	053	0	2021	29	Clear Spring Health Premier Rx (PDP)	Nevada		Nevada	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	054	0	2021	29	Clear Spring Health Premier Rx (PDP)	Oregon and Washington		Oregon and Washington	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	055	0	2021	29	Clear Spring Health Premier Rx (PDP)	Idaho and Utah		Idaho and Utah	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	056	0	2021	29	Clear Spring Health Premier Rx (PDP)	California		California	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	057	0	2021	29	Clear Spring Health Premier Rx (PDP)	Hawaii		Hawaii	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S6946	058	0	2021	29	Clear Spring Health Premier Rx (PDP)	Alaska		Alaska	1	0	0	P.O. BOX 278470		Miramar	FL	33027												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.clearspringhealthcare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.clearspringhealthcare.com	www.clearspringhealthcare.com
S7694	001	0	2021	29	Elixir RxSecure (PDP)	Maine, New Hampshire Elixir RxSecure Region 01	Elixir RxSecure (PDP)	Maine, New Hampshire Elixir RxSecure Region 01	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://elixirinsurance.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	002	0	2021	29	Elixir RxSecure (PDP)	Central New England Elixir RxSecure Region 02	Elixir RxSecure (PDP)	Central New England Elixir RxSecure Region 02	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	003	0	2021	29	Elixir RxSecure (PDP)	New York Elixir RxSecure Region 03	Elixir RxSecure (PDP)	New York Elixir RxSecure Region 03	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	004	0	2021	29	Elixir RxPlus (PDP)	New Jersey Elixir RxPlus Region 04	Elixir RxPlus (PDP)	New Jersey Elixir RxPlus Region 04	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	005	0	2021	29	Elixir RxSecure (PDP)	Mid-Atlantic Elixir RxSecure Region 05	Elixir RxSecure (PDP)	Mid-Atlantic Elixir RxSecure Region 05	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	006	0	2021	29	Elixir RxSecure (PDP)	Pennsylvania, WV Elixir RxSecure Region 06	Elixir RxSecure (PDP)	Pennsylvania, WV Elixir RxSecure Region 06	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	007	0	2021	29	Elixir RxSecure (PDP)	Virginia Elixir RxSecure Region 07	Elixir RxSecure (PDP)	Virginia Elixir RxSecure Region 07	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	008	0	2021	29	Elixir RxSecure (PDP)	North Carolina Elixir RxSecure Region 08	Elixir RxSecure (PDP)	North Carolina Elixir RxSecure Region 08	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	009	0	2021	29	Elixir RxSecure (PDP)	South Carolina Elixir RxSecure Region 09	Elixir RxSecure (PDP)	South Carolina Elixir RxSecure Region 09	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	010	0	2021	29	Elixir RxSecure (PDP)	Georgia Elixir RxSecure Region 10	Elixir RxSecure (PDP)	Georgia Elixir RxSecure Region 10	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	011	0	2021	29	Elixir RxPlus (PDP)	Florida Elixir RxPlus Region 11	Elixir RxPlus (PDP)	Florida Elixir RxPlus Region 11	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	012	0	2021	29	Elixir RxSecure (PDP)	Alabama,Tennessee Elixir RxSecure Region 12	Elixir RxSecure (PDP)	Alabama,Tennessee Elixir RxSecure Region 12	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	014	0	2021	29	Elixir RxSecure (PDP)	Ohio Elixir RxSecure Region 14	Elixir RxSecure (PDP)	Ohio Elixir RxSecure Region 14	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	015	0	2021	29	Elixir RxSecure (PDP)	Indiana, Kentucky Elixir RxSecure Region 15	Elixir RxSecure (PDP)	Indiana, Kentucky Elixir RxSecure Region 15	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	016	0	2021	29	Elixir RxPlus (PDP)	Wisconsin Elixir RxPlus Region 16	Elixir RxPlus (PDP)	Wisconsin Elixir RxPlus Region 16	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	017	0	2021	29	Elixir RxPlus (PDP)	Illinois Elixir RxPlus Region 17	Elixir RxPlus (PDP)	Illinois Elixir RxPlus Region 17	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	018	0	2021	29	Elixir RxPlus (PDP)	Missouri Elixir RxPlus Region 18	Elixir RxPlus (PDP)	Missouri Elixir RxPlus Region 18	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	019	0	2021	29	Elixir RxPlus (PDP)	Arkansas Elixir RxPlus Region 19	Elixir RxPlus (PDP)	Arkansas Elixir RxPlus Region 19	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	020	0	2021	29	Elixir RxSecure (PDP)	Mississippi Elixir RxSecure Region 20	Elixir RxSecure (PDP)	Mississippi Elixir RxSecure Region 20	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	021	0	2021	29	Elixir RxPlus (PDP)	Louisiana Elixir RxPlus Region 21	Elixir RxPlus (PDP)	Louisiana Elixir RxPlus Region 21	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	022	0	2021	29	Elixir RxSecure (PDP)	Texas Elixir RxSecure Region 22	Elixir RxSecure (PDP)	Texas Elixir RxSecure Region 22	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	023	0	2021	29	Elixir RxPlus (PDP)	Oklahoma Elixir RxPlus Region 23	Elixir RxPlus (PDP)	Oklahoma Elixir RxPlus Region 23	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	024	0	2021	29	Elixir RxPlus (PDP)	Kansas Elixir RxPlus Region 24	Elixir RxPlus (PDP)	Kansas Elixir RxPlus Region 24	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	025	0	2021	29	Elixir RxPlus (PDP)	Midwest/Plains Elixir RxPlus Region 25	Elixir RxPlus (PDP)	Midwest/Plains Elixir RxPlus Region 25	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	026	0	2021	29	Elixir RxPlus (PDP)	New Mexico Elixir RxPlus Region 26	Elixir RxPlus (PDP)	New Mexico Elixir RxPlus Region 26	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	027	0	2021	29	Elixir RxPlus (PDP)	Colorado Elixir RxPlus Region 27	Elixir RxPlus (PDP)	Colorado Elixir RxPlus Region 27	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	028	0	2021	29	Elixir RxPlus (PDP)	Arizona Elixir RxPlus Region 28	Elixir RxPlus (PDP)	Arizona Elixir RxPlus Region 28	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	029	0	2021	29	Elixir RxPlus (PDP)	Nevada Elixir RxPlus Region 29	Elixir RxPlus (PDP)	Nevada Elixir RxPlus Region 29	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	030	0	2021	29	Elixir RxSecure (PDP)	Oregon, Washington Elixir RxSecure Region 30	Elixir RxSecure (PDP)	Oregon, Washington Elixir RxSecure Region 30	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	031	0	2021	29	Elixir RxPlus (PDP)	Idaho, Utah Elixir RxPlus Region 31	Elixir RxPlus (PDP)	Idaho, Utah Elixir RxPlus Region 31	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	032	0	2021	29	Elixir RxSecure (PDP)	California Elixir RxSecure Region 32	Elixir RxSecure (PDP)	California Elixir RxSecure Region 32	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	033	0	2021	29	Elixir RxPlus (PDP)	Hawaii Elixir RxPlus Region 33	Elixir RxPlus (PDP)	Hawaii Elixir RxPlus Region 33	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	034	0	2021	29	Elixir RxPlus (PDP)	Alaska Elixir RxPlus Region 34	Elixir RxPlus (PDP)	Alaska Elixir RxPlus Region 34	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	070	0	2021	29	Elixir RxSecure (PDP)	Michigan Elixir RxSecure Region 13	Elixir RxSecure (PDP)	Michigan Elixir RxSecure Region 13	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	105	0	2021	29	Elixir RxPlus (PDP)	Puerto Rico Elixir RxPlus Region 38	Elixir RxPlus (PDP)	Puerto Rico Elixir RxPlus Region 38	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	106	0	2021	29	Elixir RxPlus (PDP)	Guam Elixir RxPlus Region 36	Elixir RxPlus (PDP)	Guam Elixir RxPlus Region 36	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	121	0	2021	29	Elixir RxPlus (PDP)	New York Elixir RxPlus Region 3	Elixir RxPlus (PDP)	New York Elixir RxPlus Region 3	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	122	0	2021	29	Elixir RxPlus (PDP)	Mid-Atlantic Elixir RxPlus Region - 05	Elixir RxPlus (PDP)	Mid-Atlantic Elixir RxPlus Region - 05	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	123	0	2021	29	Elixir RxPlus (PDP)	South Carolina Elixir RxPlus Region 09	Elixir RxPlus (PDP)	South Carolina Elixir RxPlus Region 09	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	124	0	2021	29	Elixir RxPlus (PDP)	Maine, New Hampshire Elixir RxPlus Region 01	Elixir RxPlus (PDP)	Maine, New Hampshire Elixir RxPlus Region 01	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	125	0	2021	29	Elixir RxPlus (PDP)	Central New England Elixir RxPlus Region 02	Elixir RxPlus (PDP)	Central New England Elixir RxPlus Region 02	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	126	0	2021	29	Elixir RxPlus (PDP)	Pennsylvania, W Virginia Elixir RxPlus Region 06	Elixir RxPlus (PDP)	Pennsylvania, W Virginia Elixir RxPlus Region 06	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	127	0	2021	29	Elixir RxPlus (PDP)	Virginia Elixir RxPlus Region 07	Elixir RxPlus (PDP)	Virginia Elixir RxPlus Region 07	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	128	0	2021	29	Elixir RxPlus (PDP)	North Carolina Elixir RxPlus Region 08	Elixir RxPlus (PDP)	North Carolina Elixir RxPlus Region 08	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	129	0	2021	29	Elixir RxPlus (PDP)	Georgia Elixir RxPlus Region 10	Elixir RxPlus (PDP)	Georgia Elixir RxPlus Region 10	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	130	0	2021	29	Elixir RxPlus (PDP)	Alabama/Tennessee Elixir RxPlus Region 12	Elixir RxPlus (PDP)	Alabama/Tennessee Elixir RxPlus Region 12	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	131	0	2021	29	Elixir RxPlus (PDP)	Michigan Elixir RxPlus Region 13	Elixir RxPlus (PDP)	Michigan Elixir RxPlus Region 13	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	132	0	2021	29	Elixir RxPlus (PDP)	Ohio Elixir RxPlus Region 14	Elixir RxPlus (PDP)	Ohio Elixir RxPlus Region 14	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	133	0	2021	29	Elixir RxPlus (PDP)	Indiana/Kentucky Elixir RxPlus Region 15	Elixir RxPlus (PDP)	Indiana/Kentucky Elixir RxPlus Region 15	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	134	0	2021	29	Elixir RxPlus (PDP)	Mississippi Elixir RxPlus Region 20	Elixir RxPlus (PDP)	Mississippi Elixir RxPlus Region 20	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	135	0	2021	29	Elixir RxPlus (PDP)	Texas Elixir RxPlus Region 22	Elixir RxPlus (PDP)	Texas Elixir RxPlus Region 22	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	136	0	2021	29	Elixir RxPlus (PDP)	Oregon/Washington Elixir RxPlus Region 30	Elixir RxPlus (PDP)	Oregon/Washington Elixir RxPlus Region 30	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	137	0	2021	29	Elixir RxPlus (PDP)	California Elixir RxPlus Region 32	Elixir RxPlus (PDP)	California Elixir RxPlus Region 32	1	0	0	2181 E. Aurora Rd.	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	801	0	2021	29	Employer Plan Calendar Year (PDP)	National EGWP	Plande Empleador Calendario Anual (PDP)	National EGWP	1	3	1	2181 E. Aurora Rd	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	802	0	2021	29	Employer Group Non-Calendar Year (PDP)	National EGWP	Plande Empleador No Calendario Anual (PDP)	National EGWP	1	3	1	2181 E. Aurora Rd	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
S7694	803	0	2021	29	Retiree RxCare 4TC (PDP)	National EGWP	Retiree RxCare 4TC (PDP)	National EGWP	1	3	1	50 Whitecap Drive		North Kingstown	RI	02852												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	retireerxcare.amwins.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	retireerxcare.amwins.com/
S7694	804	0	2021	29	Retiree RxCare 5TC (PDP)	National EGWP	Retiree RxCare 5TC (PDP)	National EGWP	1	3	1	50 Whitecap Drive		North Kingstown	RI	02852												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	retireerxcare.amwins.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	retireerxcare.amwins.com
S7694	805	0	2021	29	Retiree RxCare 4TO (PDP)	National EGWP	Retiree RxCare 4TO (PDP)	National EGWP	1	3	1	50 Whitecap Drive		North Kingstown	RI	02852												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	retireerxcare.amwins.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	retireerxcare.amwins.com
S7694	806	0	2021	29	Retiree RxCare 5TO (PDP)	National EGWP	Retiree RxCare 5TO (PDP)	National EGWP	1	3	1	50 Whitecap Drive		North Kingstown	RI	02852												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	retireerxcare.amwins.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	retireerxcare.amwins.com
S7694	807	0	2021	29	Retiree RxCare Bronze (PDP)	National EGWP	Retiree RxCare Bronze (PDP)	National EGWP	1	3	1	50 Whitecap Drive		North Kingstown	RI	02852												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	retireerxcare.amwins.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	retireerxcare.amwins.com
S7694	808	0	2021	29	Employer Group Broad (PDP)	National EGWP	Employer Group Broad (PDP)	National EGWP	1	3	1	2181 E. Aurora Rd	Suite 201	Twinsburg	OH	44087		CustomerService@envisionrxplus.com	CustomerService@envisionrxplus.com									2100001200200001200300001200400001200500001200600001200700001200	2100001200200001200300001200400001200500001200600001200700001200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://envisionrxplus.com		0	3			0					3	0	0		https://envisionrxplus.com/Pharmacy	https://envisionrxplus.com/Resources/Formulary
E0654	801	0	2021	30	IBT Voluntary Employee Benefits Trust (Employer PDP)	National		National	1	3	1	3700 S. Stonebridge Drive	P.O. Box 8080	McKinney	TX	75070												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.teamstarpartd.com		0	3			0					3	0	0		www.teamstarpartd.com	www.teamstarpartd.com
S5960	167	0	2021	29	Medicare Rx Basic (PDP)	New Jersey		New Jersey	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	shop.unicare.com/medicare		0	3			0					3	0	0		www.unicare.com/medicare	www.unicare.com/medicare
S5960	801	0	2021	29	MedicareRx Rewards (PDP)	All States (Nationwide)		All States (Nationwide)	1	3	1	Enrollment Processing Center	P.O. Box 110	Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	shop.unicare.com/medicare		0	3			0					3	0	0		www.unicare.com/medicare	www.unicare.com/medicare
S5960	803	0	2021	29	MedicareRx Rewards (PDP)	All States (Nationwide)		All States (Nationwide)	1	3	1	Enrollment Processing Center	P.O. Box 110	Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	shop.unicare.com/medicare		0	3			0					3	0	0		www.unicare.com/medicare	www.unicare.com/medicare
S5596	084	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Nevada		Nevada	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	803	0	2021	29	Blue MedicareRx (PDP)	VA GA OH IN KY WI CO NV CA MO ME NH (Nationwide)		VA GA OH IN KY WI CO NV CA MO ME NH (Nationwide)	1	3	1	Enrollment Processing Center	P.O. Box 110	Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	804	0	2021	29	Blue MedicareRx (PDP)	VA GA OH IN KY WI CO NV CA MO ME NH (Nationwide)		VA GA OH IN KY WI CO NV CA MO ME NH (Nationwide)	1	3	1	Enrollment Processing Center	P.O. Box 110	Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	001	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Maine and New Hampshire		Maine and New Hampshire	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	005	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Virginia		Virginia	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	006	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Virginia		Virginia	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	009	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Georgia		Georgia	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	010	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Georgia		Georgia	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	013	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Ohio		Ohio	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	014	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Ohio		Ohio	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	017	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Indiana and Kentucky		Indiana and Kentucky	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	018	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Indiana and Kentucky		Indiana and Kentucky	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	033	0	2021	29	Anthem Blue Cross MediBlue Rx Standard (PDP)	California		California	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	034	0	2021	29	Anthem Blue Cross MediBlue Rx Plus (PDP)	California		California	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	043	0	2021	29	Blue MedicareRx Value (PDP)	Missouri		Missouri	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	044	0	2021	29	Blue MedicareRx Plus (PDP)	Missouri		Missouri	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	046	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Maine and New Hampshire		Maine and New Hampshire	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	056	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Wisconsin		Wisconsin	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	057	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Wisconsin		Wisconsin	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	059	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Colorado		Colorado	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	060	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Colorado		Colorado	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	062	0	2021	29	Anthem MediBlue Rx Standard (PDP)	Nevada		Nevada	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	063	0	2021	29	Anthem MediBlue Rx Plus (PDP)	Nevada		Nevada	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0					3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	066	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Maine and New Hampshire		Maine and New Hampshire	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	068	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Virginia		Virginia	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	070	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Georgia		Georgia	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $310.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $310.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	072	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Ohio		Ohio	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	074	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Indiana and Kentucky		Indiana and Kentucky	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	076	0	2021	29	Anthem Blue Cross MediBlue Rx Enhanced (PDP)	California		California	1	0	0	Enrollment Processing Center	P.O. Box 659404	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	078	0	2021	29	Blue MedicareRx Enhanced (PDP)	Missouri		Missouri	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $240.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $240.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	080	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Wisconsin		Wisconsin	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $290.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $290.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5596	082	0	2021	29	Anthem MediBlue Rx Enhanced (PDP)	Colorado		Colorado	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.anthem.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.anthem.com/medicare	https://shop.anthem.com/medicare
S5726	013	0	2021	29	Blue MedicareRx Value (PDP)	Kansas		Kansas	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://shop.partdkansas.com/medicare		0	3			0					3	0	0		https://shop.partdkansas.com/medicare	https://shop.partdkansas.com/medicare
S5726	014	0	2021	29	Blue MedicareRx Plus (PDP)	Kansas		Kansas	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.partdkansas.com/medicare		0	3			0					3	0	0		https://shop.partdkansas.com/medicare	https://shop.partdkansas.com/medicare
S5726	019	0	2021	29	Blue MedicareRx Enhanced (PDP)	Kansas		Kansas	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://shop.partdkansas.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.partdkansas.com/medicare	https://shop.partdkansas.com/medicare
S5726	805	0	2021	29	Blue MedicareRx (PDP)	Kansas		Kansas	1	3	1	Enrollment Processing Center	P.O. Box 110	Fond du Lac	WI	54936												2000000000208002100308002100408002100508002100608002100000000000	2000000000208002100308002100408002100508002100608002100000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://shop.partdkansas.com/medicare		0	3			0					3	0	0		https://shop.partdkansas.com/medicare	https://shop.partdkansas.com/medicare
S5584	001	0	2021	29	Prescription Blue Select (PDP)	State of Michigan		State of Michigan	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	1	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare		0	3			0					3	0	0		www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
S5584	002	0	2021	29	Prescription Blue Premium (PDP)	State of Michigan		State of Michigan	1	0	0	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare		0	3			0					3	0	0		www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
S5584	801	0	2021	29	Prescription Blue Employer Plan CY (PDP)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226												2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare		0	3			0					3	0	0		www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
S5584	802	0	2021	29	Prescription Blue Employer Plan non-CY (PDP)	State of Michigan		State of Michigan	1	3	1	600 East Lafayette Blvd.	MC TC1302	Detroit	MI	48226												2000000000208301700308301700408301700508301700608301700000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bcbsm.com/medicare		0	3			0					3	0	0		www.bcbsm.com/pharmaciesmedicare	www.bcbsm.com/formularymedicare
S1030	001	0	2021	29	BlueRx Enhanced Plus (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	0	0	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	006	0	2021	29	BlueRx Essential (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	0	0	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	010	0	2021	29	BlueRx Enhanced (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	0	0	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	801	0	2021	29	BlueRx Employer Group Plan 801 (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	802	0	2021	29	BlueRx Employer Group Plan 802 (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	803	0	2021	29	BlueRx Employer Group Plan 803 (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	804	0	2021	29	BlueRx Employer Group Plan 804 (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	3	1	450 Riverchase Parkway East		Birmingham	AL	35244												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1030	805	0	2021	29	BlueRx Employer Group Plan 805 (PDP)	State of Alabama, State of Tennessee		State of Alabama, State of Tennessee	1	3	1	450 Rivierchase Parkway		Birmingham	AL	35244												3108002000208002000000000000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.bluerxalatenn.com		0	3			0					3	0	0		www.bluerxalatenn.com	www.bluerxalatenn.com
S1822	801	0	2021	29	HealthPartners Retiree National Choice CY (PDP)	Nationwide		Nationwide	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare		0	3			0					3	0	0		healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
S1822	802	0	2021	29	HealthPartners Retiree National Choice NCY (PDP)	Nationwide		Nationwide	1	3	1	8170 33rd Avenue South		Bloomington	MN	55425												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	healthpartners.com/medicare		0	3			0					3	0	0		healthpartners.com/partdpharmacy	healthpartners.com/medicarerx
S6506	001	0	2021	29	Blue MedicareRx Value (PDP)	Arizona		Arizona	1	0	0	25 Lakeview Drive		Jessup	PA	18434												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.YourAZMedicareSolutions.com		0	3			0					3	0	0		www.YourAZMedicareSolutions.com	www.YourAZMedicareSolutions.com
S6506	002	0	2021	29	Blue MedicareRx Enhanced (PDP)	Arizona		Arizona	1	0	0	25 Lakeview Drive		Jessup	PA	18434												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourAZMedicareSolutions.com		0	3			0					3	0	0		www.YourAZMedicareSolutions.com	www.YourAZMedicareSolutions.com
S6506	003	0	2021	29	Blue MedicareRx Essential (PDP)	Arizona		Arizona	1	0	0	25 Lakeview Drive		Jessup	PA	18434												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.YourAZMedicareSolutions.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $180.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $180.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.YourAZMedicareSolutions.com	www.YourAZMedicareSolutions.com
S6506	801	0	2021	29	Blue MedicareRx for Groups (PDP)	Nationwide		Nationwide	1	3	1	25 Lakeview Drive		Jessup	PA	18434												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.YourAZMedicareSolutions.com		0	3			0					3	0	0		www.YourAZMedicareSolutions.com	www.YourAZMedicareSolutions.com
S5715	001	0	2021	29	Blue Cross MedicareRx Value (PDP)	State of Illinois		State of Illinois	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/pdp		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.getblueil.com/pdp/pharmacies	www.getblueil.com/pdp/druglist
S5715	002	0	2021	29	Blue Cross MedicareRx Plus (PDP)	State of Illinois		State of Illinois	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/pdp		0	3			0					3	0	0		www.getblueil.com/pdp/pharmacies	www.getblueil.com/pdp/druglist
S5715	003	0	2021	29	Blue Cross MedicareRx Value (PDP)	State of New Mexico		State of New Mexico	1	0	0	PO Box 3897		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/pdp		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.getbluenm.com/pdp/pharmacies	www.getbluenm.com/pdp/druglist
S5715	004	0	2021	29	Blue Cross MedicareRx Plus (PDP)	State of New Mexico		State of New Mexico	1	0	0	PO Box 3897		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/pdp		0	3			0					3	0	0		www.getbluenm.com/pdp/pharmacies	www.getbluenm.com/pdp/druglist
S5715	005	0	2021	29	Blue Cross MedicareRx Value (PDP)	State of Texas		State of Texas	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/pdp		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.getbluetx.com/pdp/pharmacies	www.getbluetx.com/pdp/druglist
S5715	006	0	2021	29	Blue Cross MedicareRx Plus (PDP)	State of Texas		State of Texas	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/pdp		0	3			0					3	0	0		www.getbluetx.com/pdp/pharmacies	www.getbluetx.com/pdp/druglist
S5715	010	0	2021	29	Blue Cross MedicareRx Value (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueok.com/pdp		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.getblueok.com/pdp/pharmacies	www.getblueok.com/pdp/druglist
S5715	012	0	2021	29	Blue Cross MedicareRx Basic (PDP)	State of Illinois		State of Illinois	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.getblueil.com/pdp		0	3			0					3	0	0		www.getblueil.com/pdp/pharmacies	www.getblueil.com/pdp/druglist
S5715	013	0	2021	29	Blue Cross MedicareRx Basic (PDP)	State of New Mexico		State of New Mexico	1	0	0	PO Box 3897		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.getbluenm.com/pdp		0	3			0					3	0	0		www.getbluenm.com/pdp/pharmacies	www.getbluenm.com/pdp/druglist
S5715	014	0	2021	29	Blue Cross MedicareRx Basic (PDP)	State of Texas		State of Texas	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.getbluetx.com/pdp		0	3			0					3	0	0		www.getbluetx.com/pdp/pharmacies	www.getbluetx.com/pdp/druglist
S5715	015	0	2021	29	Blue Cross MedicareRx Basic (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.getblueok.com/pdp		0	3			0					3	0	0		www.getblueok.com/pdp/pharmacies	www.getblueok.com/pdp/druglist
S5715	018	0	2021	29	Blue Cross MedicareRx Choice (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.getblueok.com/pdp		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.getblueok.com/pdp/pharmacies	www.getblueok.com/pdp/druglist
S5715	801	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of Illinois		State of Illinois	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	802	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of New Mexico		State of New Mexico	1	3	1	PO Box 3897		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	803	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of Texas		State of Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	807	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	809	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of Oklahoma		State of Oklahoma	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	811	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of Illinois		State of Illinois	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	813	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of New Mexico		State of New Mexico	1	3	1	PO Box 3897		Scranton	PA	18505												4000000000208002000308002000408002000508002000608002000000000000	4108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	815	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	State of Texas		State of Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	817	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	Illinois, New Mexico, Oklahoma and Texas		Illinois, New Mexico, Oklahoma and Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	818	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	Illinois, New Mexico, Oklahoma, Texas		Illinois, New Mexico, Oklahoma, Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	819	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	Illinois, New Mexico, Oklahoma, Texas		Illinois, New Mexico, Oklahoma, Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	820	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	Illinois, New Mexico, Oklahoma, Texas		Illinois, New Mexico, Oklahoma, Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	821	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	Illinois, New Mexico, Oklahoma, Texas		Illinois, New Mexico, Oklahoma, Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S5715	822	0	2021	29	Blue Cross Group MedicareRx Plan (PDP)	Illinois, New Mexico, Oklahoma, Texas		Illinois, New Mexico, Oklahoma, Texas	1	3	1	PO Box 3897		Scranton	PA	18505												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hcsc.com		0	3			0					3	0	0		www.myprime.com	www.myprime.com
S9701	801	0	2021	29	Navitus MedicareRx (PDP)	Navitus MedicareRx		Navitus MedicareRx	1	3	1	1025 West Navitus Drive		Appleton	WI	54913												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://medicarerx.navitus.com/		0	3			0					3	0	0		https://medicarerx.navitus.com/	https://medicarerx.navitus.com/
S9701	802	0	2021	29	Navitus MedicareRx (PDP)	Navitus MedicareRx		Navitus MedicareRx	1	3	1	1025 West Navitus Drive		Appleton	WI	54913												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://medicarerx.navitus.com/		0	3			0					3	0	0		https://medicarerx.navitus.com/	https://medicarerx.navitus.com/
S9701	803	0	2021	29	Navitus MedicareRx (PDP)	Navitus MedicareRx		Navitus MedicareRx	1	3	1	1025 West Navitus Drive		Appleton	WI	54913												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://medicarerx.navitus.com/		0	3			0					3	0	0		https://medicarerx.navitus.com/	https://medicarerx.navitus.com/
S9701	804	0	2021	29	Navitus MedicareRx (PDP)	Navitus MedicareRx		Navitus MedicareRx	1	3	1	1025 West Navitus Drive		Appleton	WI	54913												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://medicarerx.navitus.com/		0	3			0					3	0	0		https://medicarerx.navitus.com/	https://medicarerx.navitus.com/
S9701	807	0	2021	29	Navitus MedicareRx (PDP)	Navitus MedicareRx		Navitus MedicareRx	1	3	1	1025 West Navitus Drive		Appleton	WI	54913												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://medicarerx.navitus.com/		0	3			0					3	0	0		https://medicarerx.navitus.com/	https://medicarerx.navitus.com/
S4802	012	0	2021	29	WellCare Classic (PDP)	Louisiana		Louisiana	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					1	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	013	0	2021	29	WellCare Classic (PDP)	Texas		Texas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	014	0	2021	29	WellCare Classic (PDP)	Oklahoma		Oklahoma	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	020	0	2021	29	WellCare Classic (PDP)	Oregon and Washington		Oregon and Washington	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	021	0	2021	29	WellCare Classic (PDP)	Idaho and Utah		Idaho and Utah	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	069	0	2021	29	WellCare Classic (PDP)	Virginia		Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					1	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	070	0	2021	29	WellCare Classic (PDP)	South Carolina		South Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	071	0	2021	29	WellCare Classic (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	072	0	2021	29	WellCare Classic (PDP)	Missouri		Missouri	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	073	0	2021	29	WellCare Classic (PDP)	Arkansas		Arkansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	074	0	2021	29	WellCare Classic (PDP)	Mississippi		Mississippi	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	075	0	2021	29	WellCare Classic (PDP)	Maine, New Hampshire		Maine, New Hampshire	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	076	0	2021	29	WellCare Classic (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	077	0	2021	29	WellCare Classic (PDP)	New York		New York	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	078	0	2021	29	WellCare Classic (PDP)	New Jersey		New Jersey	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	079	0	2021	29	WellCare Classic (PDP)	District of Columbia, Delaware, Maryland		District of Columbia, Delaware, Maryland	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	080	0	2021	29	WellCare Classic (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	081	0	2021	29	WellCare Classic (PDP)	North Carolina		North Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	082	0	2021	29	WellCare Classic (PDP)	Georgia		Georgia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	083	0	2021	29	WellCare Classic (PDP)	Florida		Florida	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					1	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	084	0	2021	29	WellCare Classic (PDP)	Michigan		Michigan	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	085	0	2021	29	WellCare Classic (PDP)	Ohio		Ohio	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	086	0	2021	29	WellCare Classic (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	087	0	2021	29	WellCare Classic (PDP)	Illinois		Illinois	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	088	0	2021	29	WellCare Classic (PDP)	Kansas		Kansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	089	0	2021	29	WellCare Classic (PDP)	IA, MN, MT, NE, ND, SD, WY		IA, MN, MT, NE, ND, SD, WY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					1	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	090	0	2021	29	WellCare Classic (PDP)	New Mexico		New Mexico	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	091	0	2021	29	WellCare Classic (PDP)	Colorado		Colorado	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	092	0	2021	29	WellCare Classic (PDP)	Arizona		Arizona	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					1	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	093	0	2021	29	WellCare Classic (PDP)	Nevada		Nevada	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	094	0	2021	29	WellCare Classic (PDP)	California		California	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	095	0	2021	29	WellCare Classic (PDP)	Hawaii		Hawaii	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	096	0	2021	29	WellCare Classic (PDP)	Alaska		Alaska	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	097	0	2021	29	WellCare Classic (PDP)	Wisconsin		Wisconsin	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	132	0	2021	29	WellCare Value Script (PDP)	Wisconsin		Wisconsin	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	133	0	2021	29	WellCare Value Script (PDP)	Louisiana		Louisiana	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	134	0	2021	29	WellCare Value Script (PDP)	Arizona		Arizona	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	135	0	2021	29	WellCare Value Script (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	136	0	2021	29	WellCare Value Script (PDP)	Maine, New Hampshire		Maine, New Hampshire	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	137	0	2021	29	WellCare Value Script (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	138	0	2021	29	WellCare Value Script (PDP)	New York		New York	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	139	0	2021	29	WellCare Value Script (PDP)	New Jersey		New Jersey	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	140	0	2021	29	WellCare Value Script (PDP)	District of Columbia, Delaware, Maryland		District of Columbia, Delaware, Maryland	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	141	0	2021	29	WellCare Value Script (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	142	0	2021	29	WellCare Value Script (PDP)	Virginia		Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	143	0	2021	29	WellCare Value Script (PDP)	North Carolina		North Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	144	0	2021	29	WellCare Value Script (PDP)	South Carolina		South Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	145	0	2021	29	WellCare Value Script (PDP)	Georgia		Georgia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	146	0	2021	29	WellCare Value Script (PDP)	Florida		Florida	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	147	0	2021	29	WellCare Value Script (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	148	0	2021	29	WellCare Value Script (PDP)	Michigan		Michigan	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	149	0	2021	29	WellCare Value Script (PDP)	Ohio		Ohio	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	150	0	2021	29	WellCare Value Script (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	151	0	2021	29	WellCare Value Script (PDP)	Illinois		Illinois	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	152	0	2021	29	WellCare Value Script (PDP)	Missouri		Missouri	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	153	0	2021	29	WellCare Value Script (PDP)	Arkansas		Arkansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	154	0	2021	29	WellCare Value Script (PDP)	Mississippi		Mississippi	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	155	0	2021	29	WellCare Value Script (PDP)	Texas		Texas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	156	0	2021	29	WellCare Value Script (PDP)	Oklahoma		Oklahoma	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	157	0	2021	29	WellCare Value Script (PDP)	Kansas		Kansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	158	0	2021	29	WellCare Value Script (PDP)	IA, MN, MT, ND, NE, SD, WY		IA, MN, MT, ND, NE, SD, WY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	159	0	2021	29	WellCare Value Script (PDP)	New Mexico		New Mexico	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	160	0	2021	29	WellCare Value Script (PDP)	Colorado		Colorado	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	161	0	2021	29	WellCare Value Script (PDP)	Nevada		Nevada	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	162	0	2021	29	WellCare Value Script (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	163	0	2021	29	WellCare Value Script (PDP)	California		California	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	164	0	2021	29	WellCare Value Script (PDP)	Hawaii		Hawaii	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	165	0	2021	29	WellCare Value Script (PDP)	Alaska		Alaska	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	170	0	2021	29	WellCare Wellness Rx (PDP)	Maine, New Hampshire		Maine, New Hampshire	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	171	0	2021	29	WellCare Wellness Rx (PDP)	Connecticut, Massachusetts, Rhode Island, Vermont		Connecticut, Massachusetts, Rhode Island, Vermont	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	172	0	2021	29	WellCare Wellness Rx (PDP)	New York		New York	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	173	0	2021	29	WellCare Wellness Rx (PDP)	New Jersey		New Jersey	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	174	0	2021	29	WellCare Wellness Rx (PDP)	Delaware, District of Columbia, Maryland		Delaware, District of Columbia, Maryland	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	175	0	2021	29	WellCare Wellness Rx (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	176	0	2021	29	WellCare Wellness Rx (PDP)	Virginia		Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	177	0	2021	29	WellCare Wellness Rx (PDP)	North Carolina		North Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	178	0	2021	29	WellCare Wellness Rx (PDP)	South Carolina		South Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	179	0	2021	29	WellCare Wellness Rx (PDP)	Georgia		Georgia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	180	0	2021	29	WellCare Wellness Rx (PDP)	Florida		Florida	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	181	0	2021	29	WellCare Wellness Rx (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	182	0	2021	29	WellCare Wellness Rx (PDP)	Michigan		Michigan	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	183	0	2021	29	WellCare Wellness Rx (PDP)	Ohio		Ohio	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	184	0	2021	29	WellCare Wellness Rx (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	185	0	2021	29	WellCare Wellness Rx (PDP)	Wisconsin		Wisconsin	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	186	0	2021	29	WellCare Wellness Rx (PDP)	Illinois		Illinois	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	187	0	2021	29	WellCare Wellness Rx (PDP)	Missouri		Missouri	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	188	0	2021	29	WellCare Wellness Rx (PDP)	Arkansas		Arkansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	189	0	2021	29	WellCare Wellness Rx (PDP)	Mississippi		Mississippi	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	190	0	2021	29	WellCare Wellness Rx (PDP)	Louisiana		Louisiana	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	191	0	2021	29	WellCare Wellness Rx (PDP)	Texas		Texas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	192	0	2021	29	WellCare Wellness Rx (PDP)	Oklahoma		Oklahoma	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	193	0	2021	29	WellCare Wellness Rx (PDP)	Kansas		Kansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	194	0	2021	29	WellCare Wellness Rx (PDP)	IA, MN, MT, ND, NE, SD, WY		IA, MN, MT, ND, NE, SD, WY	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	195	0	2021	29	WellCare Wellness Rx (PDP)	New Mexico		New Mexico	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	196	0	2021	29	WellCare Wellness Rx (PDP)	Colorado		Colorado	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	197	0	2021	29	WellCare Wellness Rx (PDP)	Arizona		Arizona	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	198	0	2021	29	WellCare Wellness Rx (PDP)	Nevada		Nevada	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	199	0	2021	29	WellCare Wellness Rx (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	200	0	2021	29	WellCare Wellness Rx (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	201	0	2021	29	WellCare Wellness Rx (PDP)	California		California	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	202	0	2021	29	WellCare Wellness Rx (PDP)	Hawaii		Hawaii	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4802	203	0	2021	29	WellCare Wellness Rx (PDP)	Alaska		Alaska	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			2	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S4501	812	0	2021	29	Pharmacy Benefit Dimensions PDP-12 (WD) (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	813	0	2021	29	Pharmacy Benefit Dimensions PDP-13 (WD) (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	814	0	2021	29	Pharmacy Benefit Dimensions PDP-14 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	815	0	2021	29	Pharmacy Benefit Dimensions PDP-15 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	816	0	2021	29	Pharmacy Benefit Dimensions PDP-16 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	801	0	2021	29	Pharmacy Benefit Dimensions PDP-1 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Drive		Buffalo	NY	14221		sales@independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com/medicare		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	802	0	2021	29	Pharmacy Benefit Dimensions PDP-2 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	803	0	2021	29	Pharmacy Benefit Dimensions PDP-3 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	independenthealth.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	804	0	2021	29	Pharmacy Benefit Dimensions PDP-4 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	805	0	2021	29	Pharmacy Benefit Dimensions PDP-5 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	806	0	2021	29	Pharmacy Benefit Dimensions PDP-6 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	807	0	2021	29	Pharmacy Benefit Dimensions PDP-7 (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.independenthealth.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	808	0	2021	29	Pharmacy Benefit Dimemsions PDP-8 (WD) (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	809	0	2021	29	Pharmacy Benefit Dimensions PDP-9 (WD) (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	810	0	2021	29	Pharmacy Benefit Dimensions PDP-10 (WD) (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S4501	811	0	2021	29	Pharmacy Benefit Dimensions PDP-11 (WD) (PDP)	All regions		All regions	1	3	1	511 Farber Lakes Dr		Buffalo	NY	14221		memberservice@servicing.independenthealth.com	memberservice@servicing.independenthealth.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.pbdrx.com		0	3			0					3	0	0		www.pbdrx.com	www.pbdrx.com
S5450	801	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S5450	802	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S5450	803	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S5450	804	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S5450	805	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S5450	806	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S5450	807	0	2021	29	BlueScripts (PDP)	38 PDP Regions		38 PDP Regions	1	3	1	1 Cameron Hill Circle		Chattanooga	TN	37402												2000000000208002100308002100408002100508002100608002100000000000	2108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	bcbstmedicare.com		0	3			0					3	0	0		bcbstmedicare.com	bcbstmedicare.com
S2668	005	0	2021	29	Farm Bureau Essential Rx (PDP)	Alabama and Tennessee		Alabama and Tennessee	1	0	0	P.O. Box 266380		Weston	FL	33326												3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.fbhealthplans.com/part-d		0	3			0					3	0	0		fbhealthplans.complaceholder	www.fbhealthplans.com/part-d/essentialrx
S2668	006	0	2021	29	Farm Bureau Select Rx (PDP)	Alabama and Tennessee		Alabama and Tennessee	1	0	0	P.O. Box 266380		Weston	FL	33326												3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.fbhealthplans.com/part-d/		0	3			0					3	0	0		fbhealthplans.complaceholder	www.fbhealthplans.com/part-d/selectrx
S5820	817	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	818	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	819	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	820	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	821	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	822	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	823	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	824	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	825	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	826	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	827	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	828	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	829	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	830	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	831	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	832	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	833	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	834	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicareRx.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	835	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicareRx.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	836	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicareRx.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	001	0	2021	29	AARP MedicareRx Preferred (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	002	0	2021	29	AARP MedicareRx Preferred (PDP)	Central New England (CT, MA, RI, VT)		Central New England (CT, MA, RI, VT)	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	003	0	2021	29	AARP MedicareRx Preferred (PDP)	New Jersey		New Jersey	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	004	0	2021	29	AARP MedicareRx Preferred (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	005	0	2021	29	AARP MedicareRx Preferred (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	006	0	2021	29	AARP MedicareRx Preferred (PDP)	Virginia		Virginia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	007	0	2021	29	AARP MedicareRx Preferred (PDP)	North Carolina		North Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	008	0	2021	29	AARP MedicareRx Preferred (PDP)	South Carolina		South Carolina	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	009	0	2021	29	AARP MedicareRx Preferred (PDP)	Georgia		Georgia	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	010	0	2021	29	AARP MedicareRx Preferred (PDP)	Florida		Florida	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	011	0	2021	29	AARP MedicareRx Preferred (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	012	0	2021	29	AARP MedicareRx Preferred (PDP)	Michigan		Michigan	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	013	0	2021	29	AARP MedicareRx Preferred (PDP)	Ohio		Ohio	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	014	0	2021	29	AARP MedicareRx Preferred (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	015	0	2021	29	AARP MedicareRx Preferred (PDP)	Wisconsin		Wisconsin	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	016	0	2021	29	AARP MedicareRx Preferred (PDP)	Illinois		Illinois	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	017	0	2021	29	AARP MedicareRx Preferred (PDP)	Missouri		Missouri	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	018	0	2021	29	AARP MedicareRx Preferred (PDP)	Arkansas		Arkansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	019	0	2021	29	AARP MedicareRx Preferred (PDP)	Mississippi		Mississippi	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	020	0	2021	29	AARP MedicareRx Preferred (PDP)	Louisiana		Louisiana	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	021	0	2021	29	AARP MedicareRx Preferred (PDP)	Texas		Texas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	022	0	2021	29	AARP MedicareRx Preferred (PDP)	Oklahoma		Oklahoma	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	023	0	2021	29	AARP MedicareRx Preferred (PDP)	Kansas		Kansas	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	024	0	2021	29	AARP MedicareRx Preferred (PDP)	Upper Midwest and Northern Plains		Upper Midwest and Northern Plains	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	025	0	2021	29	AARP MedicareRx Preferred (PDP)	New Mexico		New Mexico	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	026	0	2021	29	AARP MedicareRx Preferred (PDP)	Colorado		Colorado	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	027	0	2021	29	AARP MedicareRx Preferred (PDP)	Arizona		Arizona	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	028	0	2021	29	AARP MedicareRx Preferred (PDP)	Nevada		Nevada	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	029	0	2021	29	AARP MedicareRx Preferred (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	030	0	2021	29	AARP MedicareRx Preferred (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	031	0	2021	29	AARP MedicareRx Preferred (PDP)	California		California	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	032	0	2021	29	AARP MedicareRx Preferred (PDP)	Hawaii		Hawaii	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	033	0	2021	29	AARP MedicareRx Preferred (PDP)	Alaska		Alaska	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	034	0	2021	29	AARP MedicareRx Preferred (PDP)	American Samoa		American Samoa	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	035	0	2021	29	AARP MedicareRx Preferred (PDP)	Guam		Guam	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	036	0	2021	29	AARP MedicareRx Preferred (PDP)	Northern Mariana Islands		Northern Mariana Islands	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	037	0	2021	29	AARP MedicareRx Preferred (PDP)	Puerto Rico		Puerto Rico	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	038	0	2021	29	AARP MedicareRx Preferred (PDP)	US Virgin Islands		US Virgin Islands	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5820	803	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	804	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	807	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	808	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	810	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	811	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	812	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	813	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	814	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	815	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5820	816	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S2468	003	0	2021	29	Blue Shield Rx Plus (PDP)	State of California	Blue Shield Rx Plus (PDP)	State of California	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367												5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		blueshieldca.com/med_pharmacy	blueshieldca.com/medformulary2021
S2468	004	0	2021	29	Blue Shield Rx Enhanced (PDP)	State of California	Blue Shield Rx Enhanced (PDP)	State of California	1	0	0	6300 Canoga Avenue		Woodland Hills	CA	91367												5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare		0	3			0					3	0	0		blueshieldca.com/med_pharmacy	blueshieldca.com/medformulary2021
S2468	801	0	2021	29	Blue Shield of California Medicare Rx Plan (PDP)	PDP Employer Group Plan	Blue Shield of California Medicare Rx Plan (PDP)	PDP Employer Group Plan	1	3	1	6300 Canoga Avenue		Woodland Hills	CA	91367												5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare		0	3			0					3	0	0		blueshieldca.com/med_pharmacy	blueshieldca.com/medformulary2021
S2468	802	0	2021	29	Blue Shield of California Medicare Rx Plan (PDP)	PDP Employer Group Plan	Blue Shield of California Medicare Rx Plan (PDP)	PDP Employer Group Plan	1	3	1	6300 Canoga Avenue		Woodland Hills	CA	91367												5108001700208002000308002000408002000508002000608002000708001700	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	blueshieldca.com/medicare		0	3			0					3	0	0		blueshieldca.com/med_pharmacy	blueshieldca.com/medformulary2021
S7126	001	0	2021	29	Mutual of Omaha Rx Plus (PDP)	Northern New England		Northern New England	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	002	0	2021	29	Mutual of Omaha Rx Plus (PDP)	Central New England		Central New England	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	003	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of New Jersey		State of New Jersey	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	004	0	2021	29	Mutual of Omaha Rx Plus (PDP)	Mid-Atlantic		Mid-Atlantic	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	005	0	2021	29	Mutual of Omaha Rx Plus (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	006	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Virginia		State of Virginia	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	007	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of North Carolina		State of North Carolina	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	008	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of South Carolina		State of South Carolina	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	009	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Georgia		State of Georgia	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	010	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Florida		State of Florida	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	011	0	2021	29	Mutual of Omaha Rx Plus (PDP)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	012	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Michigan		State of Michigan	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	013	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Ohio		State of Ohio	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	014	0	2021	29	Mutual of Omaha Rx Plus (PDP)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	015	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	016	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Illinois		State of Illinois	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	017	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Missouri		State of Missouri	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	018	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Arkansas		State of Arkansas	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	019	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Mississippi		State of Mississippi	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	020	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Louisiana		State of Louisiana	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	021	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Texas		State of Texas	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	022	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	023	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Kansas		State of Kansas	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	024	0	2021	29	Mutual of Omaha Rx Plus (PDP)	Upper Midwest and Northern Plains		Upper Midwest and Northern Plains	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	025	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of New Mexico		State of New Mexico	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	026	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Colorado		State of Colorado	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	027	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Arizona		State of Arizona	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	028	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Nevada		State of Nevada	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	029	0	2021	29	Mutual of Omaha Rx Plus (PDP)	States of Oregon and Washington		States of Oregon and Washington	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	030	0	2021	29	Mutual of Omaha Rx Plus (PDP)	States of Idaho and Utah		States of Idaho and Utah	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	031	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of California		State of California	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	032	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Hawaii		State of Hawaii	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	033	0	2021	29	Mutual of Omaha Rx Plus (PDP)	State of Alaska		State of Alaska	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0					3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	071	0	2021	29	Mutual of Omaha Rx Premier (PDP)	Northern New England		Northern New England	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	072	0	2021	29	Mutual of Omaha Rx Premier (PDP)	Central New England		Central New England	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	073	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of New Jersey		State of New Jersey	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	074	0	2021	29	Mutual of Omaha Rx Premier (PDP)	Mid-Atlantic		Mid-Atlantic	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	075	0	2021	29	Mutual of Omaha Rx Premier (PDP)	States of Pennsylvania and West Virginia		States of Pennsylvania and West Virginia	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	076	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Virginia		State of Virginia	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	077	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of North Carolina		State of North Carolina	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	078	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of South Carolina		State of South Carolina	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	079	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Georgia		State of Georgia	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	080	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Florida		State of Florida	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	081	0	2021	29	Mutual of Omaha Rx Premier (PDP)	States of Alabama and Tennessee		States of Alabama and Tennessee	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	082	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Michigan		State of Michigan	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	083	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Ohio		State of Ohio	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	084	0	2021	29	Mutual of Omaha Rx Premier (PDP)	States of Indiana and Kentucky		States of Indiana and Kentucky	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	085	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Wisconsin		State of Wisconsin	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	086	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Illinois		State of Illinois	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	087	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Missouri		State of Missouri	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	088	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Arkansas		State of Arkansas	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	089	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Mississippi		State of Mississippi	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	090	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Louisiana		State of Louisiana	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	091	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Texas		State of Texas	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	092	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Oklahoma		State of Oklahoma	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	093	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Kansas		State of Kansas	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	094	0	2021	29	Mutual of Omaha Rx Premier (PDP)	Upper Midwest and Northern Plains		Upper Midwest and Northern Plains	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	095	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of New Mexico		State of New Mexico	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	096	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Colorado		State of Colorado	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	097	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Arizona		State of Arizona	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	098	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Nevada		State of Nevada	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	099	0	2021	29	Mutual of Omaha Rx Premier (PDP)	States of Oregon and Washington		States of Oregon and Washington	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	100	0	2021	29	Mutual of Omaha Rx Premier (PDP)	States of Idaho and Utah		States of Idaho and Utah	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	101	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of California		State of California	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	102	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Hawaii		State of Hawaii	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S7126	103	0	2021	29	Mutual of Omaha Rx Premier (PDP)	State of Alaska		State of Alaska	1	0	0	PO Box 66535		St. Louis	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.mutualofomaharx.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.mutualofomaharx.com	www.mutualofomaharx.com
S5588	802	0	2021	29	Paramount Std. Prescription Drug Plan Empl (PDP)	Paramount Standard Prescription Drug Plan (Ohio)		Paramount Standard Prescription Drug Plan (Ohio)	1	3	1	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	paramounthealthcare.com		0	3			0					3	0	0		http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
S5588	803	0	2021	29	Paramount Enh. Prescription Drug Plan Empl (PDP)	Paramount Enhanced Prescription Drug Plan (Ohio)		Paramount Enhanced Prescription Drug Plan (Ohio)	1	3	1	P.O. Box 928		Toledo	OH	43697		brianna.eighmey@promedica.org	brianna.eighmey@promedica.org									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	paramounthealthcare.com		0	3			0					3	0	0		http://www.paramounthealthcare.com/medicareplans	http://www.paramounthealthcare.com/medicareplans
S5609	001	0	2021	29	Asuris Medicare Script Basic (PDP)	Region of Oregon and Washington		Region of Oregon and Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.asuris.com/medicare	www.asuris.com/medicare
S5609	002	0	2021	29	Asuris Medicare Script Enhanced (PDP)	Region of Oregon and Washington		Region of Oregon and Washington	1	0	0	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare		0	3			0					3	0	0		www.asuris.com/medicare	www.asuris.com/medicare
S5609	802	0	2021	29	Asuris Medicare Script (PDP)	Nationwide except territories		Nationwide except territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare		0	3			0					3	0	0		www.asuris.com/medicare	www.asuris.com/medicare
S5609	804	0	2021	29	Asuris Medicare Script 02 (PDP)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare		0	3			0					3	0	0		www.asuris.com/medicare	www.asuris.com/medicare
S5609	805	0	2021	29	Asuris Medicare Script 03 (PDP)	Nationwide except Territories		Nationwide except Territories	1	3	1	PO Box 1827	M/S B32G	Medford	OR	97501												5000000000208002000308002000408002000508002000608002000000000000	5108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.asuris.com/medicare		0	3			0					3	0	0		www.asuris.com/medicare	www.asuris.com/medicare
S5966	003	0	2021	29	EmblemHealth VIP Rx (PDP)	New York		New York	1	0	0	PO Box 4001		Farmington	CT	06034												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare		0	3			0					3	0	0		www.emblemhealth.com	emblemhealth.com/medicare
S5966	004	0	2021	29	EmblemHealth VIP Rx Plus (PDP)	New York		New York	1	0	0	PO Box 4001		Farmington	CT	06034												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	emblemhealth.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.emblemhealth.com	emblemhealth.com/medicare
S5966	803	0	2021	29	EmblemHealth National Drug Plan (PDP)	United States		United States	1	3	1	PO Box 4001		Farmington	CT	06034												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.emblemhealth.com		0	3			0					3	0	0		www.emblemhealth.com	www.emblemhealth.com
S5966	804	0	2021	29	EmblemHealth National Drug Plan (PDP)	United States		United States	1	3	1	PO Box 4001		Farmington	CT	06034												2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.emblemhealth.com		0	3			0					3	0	0		www.emblemhealth.com	www.emblemhealth.com
E3014	801	0	2021	30	PSERS Health Options Program (Employer PDP)	National		National	1	3	1	1280 N. Plum St.		Lancaster	PA	17601												2000000000208002000308002000408002000508002000608002000000000000	2000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopbenefits.com		0	3			0					3	0	0		www.hopbenefits.com	www.hopbenefits.com
E3014	802	0	2021	30	PSERS Health Options Program Value (Employer PDP)	National		National	1	3	1	1280 N. Plum St.		Lancaster	PA	17601												2000000000208002000308002000408002000508002000608002000000000000	2000000000208002000308002000408002000508002000608002000000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.hopbenefits.com		0	3			0					3	0	0		www.hopbenefits.com	www.hopbenefits.com
X0001	010	0	2021	46	Limited Income NET Program (Point-of-Sale CTR)	Medicare's Limited Income NET Program		Medicare's Limited Income NET Program	1	4	0	P.O. Box 14310		Lexington	KY	40512													2000000000208002300308002300408002300508002300608002300000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/LINET		0	3			0					3	0	0		www.humana.com/Medicare/medicare_prescription_drugs	www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
X0001	011	0	2021	46	Limited Income NET Program (Point-of-Sale CTR)	Medicare's Limited Income NET Program		Medicare's Limited Income NET Program	1	4	0	P.O. Box 14310		Lexington	KY	40512													2000000000208002300308002300408002300508002300608002300000000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/LINET		0	3			0					3	0	0		www.humana.com/Medicare/medicare_prescription_drugs	www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S5540	002	0	2021	29	Blue Medicare Rx Standard (PDP)	North Carolina		North Carolina	1	0	0	PO Box 17509		Winston Salem	NC	27116		medsup.info@bcbsnc.com										2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $365.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $365.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
S5540	004	0	2021	29	Blue Medicare Rx Enhanced (PDP)	North Carolina		North Carolina	1	0	0	PO Box 17509		Winston Salem	NC	27116		medsup.info@bcbsnc.com										2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare		0	3			0					3	0	0		https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
S5540	801	0	2021	29	Blue Medicare Rx EGWP (PDP)	National Employer Group Retirees		National Employer Group Retirees	1	3	1	PO Box 17509		Winston Salem	NC	27116		medsup.info@bcbsnc.com										2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare		0	3			0					3	0	0		https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
S5540	802	0	2021	29	Blue Medicare Rx EGWP Value (PDP)	NC Employer Groups		NC Employer Groups	1	3	1	PO Box 17509		Winston Salem	NC	27116		medsup.info@bcbsnc.com										2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare		0	3			0					3	0	0		https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
S5540	803	0	2021	29	Blue Medicare Rx EGWP Complete (PDP)	NC Employer Groups		NC Employer Groups	1	3	1	P.O. Box 17509		Winston Salem	NC	27116		medsup.info@bcbsnc.com										2108002000208002000308002000408002000508002000608002000708002000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	https://www.bluecrossnc.com/medicare		0	3			0					3	0	0		https://www.myprime.com/en/find-pharmacy.html	https://www.bluecrossnc.com/find-a-drug-or-pharmacy
S2874	001	0	2021	29	Humana Premier Rx Plan (PDP)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002000308002000408002000508002000608002000707001800	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $305.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $305.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S2874	004	0	2021	29	Humana Basic Rx Plan (PDP)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	0	0	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									9000000000208002000308002000408002000508002000608002000707001800	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S2874	801	0	2021	29	Humana Medicare Employer (PDP)	Puerto Rico - Island Wide		Puerto Rico - Island Wide	1	3	1	PO Box 195560		San Juan	PR	00919			MedicarePRTeam@humana.com									1000000000208002100308002100408002100508002100608002100000000000	1108002100208002100308002100408002100508002100608002100708002100	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.humana.com/medicare		0	3			0					3	0	0		https://www.humana.com/pharmacy/	http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/
S0586	801	0	2021	29	MVP RxCare - Employer Group (PDP)	United States and Puerto Rico		United States and Puerto Rico	1	3	1	220 Alexander St.	Medicare Sales	Rochester	NY	14607		ShopMVPMedicare@mvphealthcare.com	memberservices@mvphealthcare.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.mvphealthcare.com		0	3			0					3	0	0		https://www.mvphealthcare.com/partD	https://www.mvphealthcare.com/partD
S5810	035	0	2021	29	WellCare Medicare Rx Saver (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	036	0	2021	29	WellCare Medicare Rx Saver (PDP)	Central New England  (CT, RI, MA, VT)		Central New England  (CT, RI, MA, VT)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	037	0	2021	29	WellCare Medicare Rx Saver (PDP)	New  York		New  York	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	038	0	2021	29	WellCare Medicare Rx Saver (PDP)	New Jersey		New Jersey	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	039	0	2021	29	WellCare Medicare Rx Saver (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	040	0	2021	29	WellCare Medicare Rx Saver (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	041	0	2021	29	WellCare Medicare Rx Saver (PDP)	Virginia		Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	042	0	2021	29	WellCare Medicare Rx Saver (PDP)	North Carolina		North Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	043	0	2021	29	WellCare Medicare Rx Saver (PDP)	South Carolina		South Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	044	0	2021	29	WellCare Medicare Rx Saver (PDP)	Georgia		Georgia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	045	0	2021	29	WellCare Medicare Rx Saver (PDP)	Florida		Florida	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	046	0	2021	29	WellCare Medicare Rx Saver (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	047	0	2021	29	WellCare Medicare Rx Saver (PDP)	Michigan		Michigan	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	048	0	2021	29	WellCare Medicare Rx Saver (PDP)	Ohio		Ohio	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	049	0	2021	29	WellCare Medicare Rx Saver (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	050	0	2021	29	WellCare Medicare Rx Saver (PDP)	Wisconsin		Wisconsin	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	051	0	2021	29	WellCare Medicare Rx Saver (PDP)	Illinois		Illinois	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	052	0	2021	29	WellCare Medicare Rx Saver (PDP)	Missouri		Missouri	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	053	0	2021	29	WellCare Medicare Rx Saver (PDP)	Arkansas		Arkansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	054	0	2021	29	WellCare Medicare Rx Saver (PDP)	Mississippi		Mississippi	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	055	0	2021	29	WellCare Medicare Rx Saver (PDP)	Louisiana		Louisiana	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	056	0	2021	29	WellCare Medicare Rx Saver (PDP)	Texas		Texas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	057	0	2021	29	WellCare Medicare Rx Saver (PDP)	Oklahoma		Oklahoma	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	058	0	2021	29	WellCare Medicare Rx Saver (PDP)	Kansas		Kansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	059	0	2021	29	WellCare Medicare Rx Saver (PDP)	Upper MW and N Plains (IA, MN, NE, SD, ND, WY, MT)		Upper MW and N Plains (IA, MN, NE, SD, ND, WY, MT)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	060	0	2021	29	WellCare Medicare Rx Saver (PDP)	New Mexico		New Mexico	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	061	0	2021	29	WellCare Medicare Rx Saver (PDP)	Colorado		Colorado	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	062	0	2021	29	WellCare Medicare Rx Saver (PDP)	Arizona		Arizona	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	063	0	2021	29	WellCare Medicare Rx Saver (PDP)	Nevada		Nevada	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	064	0	2021	29	WellCare Medicare Rx Saver (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	065	0	2021	29	WellCare Medicare Rx Saver (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	066	0	2021	29	WellCare Medicare Rx Saver (PDP)	California		California	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	067	0	2021	29	WellCare Medicare Rx Saver (PDP)	Hawaii		Hawaii	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	068	0	2021	29	WellCare Medicare Rx Saver (PDP)	Alaska		Alaska	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0					3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	276	0	2021	29	WellCare Medicare Rx Select (PDP)	Central New England (CT, RI, MA, VT)		Central New England (CT, RI, MA, VT)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	277	0	2021	29	WellCare Medicare Rx Select (PDP)	New York		New York	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	278	0	2021	29	WellCare Medicare Rx Select (PDP)	New Jersey		New Jersey	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $345.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $345.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	279	0	2021	29	WellCare Medicare Rx Select (PDP)	Mid-Atlantic (DE, DC, MD)		Mid-Atlantic (DE, DC, MD)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $425.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $425.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	280	0	2021	29	WellCare Medicare Rx Select (PDP)	Pennsylvania, West Virginia		Pennsylvania, West Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $415.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $415.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	281	0	2021	29	WellCare Medicare Rx Select (PDP)	Virginia		Virginia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	282	0	2021	29	WellCare Medicare Rx Select (PDP)	North Carolina		North Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $365.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $365.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	283	0	2021	29	WellCare Medicare Rx Select (PDP)	South Carolina		South Carolina	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	284	0	2021	29	WellCare Medicare Rx Select (PDP)	Georgia		Georgia	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	285	0	2021	29	WellCare Medicare Rx Select (PDP)	Florida		Florida	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	286	0	2021	29	WellCare Medicare Rx Select (PDP)	Alabama, Tennessee		Alabama, Tennessee	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	287	0	2021	29	WellCare Medicare Rx Select (PDP)	Michigan		Michigan	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $315.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $315.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	288	0	2021	29	WellCare Medicare Rx Select (PDP)	Ohio		Ohio	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	289	0	2021	29	WellCare Medicare Rx Select (PDP)	Indiana, Kentucky		Indiana, Kentucky	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $415.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $415.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	290	0	2021	29	WellCare Medicare Rx Select (PDP)	Wisconsin		Wisconsin	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $300.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $300.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	291	0	2021	29	WellCare Medicare Rx Select (PDP)	Illinois		Illinois	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	292	0	2021	29	WellCare Medicare Rx Select (PDP)	Louisiana		Louisiana	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $385.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $385.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	293	0	2021	29	WellCare Medicare Rx Select (PDP)	Texas		Texas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $415.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $415.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	294	0	2021	29	WellCare Medicare Rx Select (PDP)	Arizona		Arizona	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	295	0	2021	29	WellCare Medicare Rx Select (PDP)	California		California	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $385.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $385.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	296	0	2021	29	WellCare Medicare Rx Select (PDP)	Northern New England (NH, ME)		Northern New England (NH, ME)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	297	0	2021	29	WellCare Medicare Rx Select (PDP)	Missouri		Missouri	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $330.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $330.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	298	0	2021	29	WellCare Medicare Rx Select (PDP)	Arkansas		Arkansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	299	0	2021	29	WellCare Medicare Rx Select (PDP)	Mississippi		Mississippi	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $415.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $415.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	300	0	2021	29	WellCare Medicare Rx Select (PDP)	Oklahoma		Oklahoma	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	301	0	2021	29	WellCare Medicare Rx Select (PDP)	Kansas		Kansas	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $400.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $400.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	302	0	2021	29	WellCare Medicare Rx Select (PDP)	Upper MW and N Plains (IA, MN, NE, SD, ND, WY, MT)		Upper MW and N Plains (IA, MN, NE, SD, ND, WY, MT)	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	303	0	2021	29	WellCare Medicare Rx Select (PDP)	New Mexico		New Mexico	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	304	0	2021	29	WellCare Medicare Rx Select (PDP)	Colorado		Colorado	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	305	0	2021	29	WellCare Medicare Rx Select (PDP)	Nevada		Nevada	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	306	0	2021	29	WellCare Medicare Rx Select (PDP)	Oregon, Washington		Oregon, Washington	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	307	0	2021	29	WellCare Medicare Rx Select (PDP)	Idaho, Utah		Idaho, Utah	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $425.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $425.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	308	0	2021	29	WellCare Medicare Rx Select (PDP)	Hawaii		Hawaii	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S5810	309	0	2021	29	WellCare Medicare Rx Select (PDP)	Alaska		Alaska	1	0	0	Attn: Pre Enrollment	PO Box 31685	Tampa	FL	33631			ricardo.morales@wellcare.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.wellcare.com/PDP		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.wellcare.com/PDP	www.wellcare.com/PDP
S8841	803	0	2021	29	OptumRx CORE Silver 2021 - CY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	804	0	2021	29	OptumRx CORE Silver 2021 - NCY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	807	0	2021	29	OptumRx CORE Bronze 2021 - CY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	808	0	2021	29	OptumRx CORE Bronze 2021 - NCY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	810	0	2021	29	MPSERS 2021 (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	812	0	2021	29	OptumRx CORE Gold 5-Tier 2021 - CY (PDP)	National		National	1	3	1	2441 Warrenville Rd		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	813	0	2021	29	OptumRx CORE Gold 5-Tier 2021 - NCY (PDP)	National		National	1	3	1	2441 Warrenville Rd		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	814	0	2021	29	OptumRx CORE PDP 2021 - CY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	815	0	2021	29	OptumRx CORE PDP 2021 - NCY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3100000000200000000300000000400000000500000000600000000700000000	3100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	816	0	2021	29	OptumRx CORE Copper 2021 - CY (PDP)	National		National	1	3	1	2441 Warrenville Road		Lisle	IL	60532												3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S8841	817	0	2021	29	OptumRx CORE Copper 2021 - NCY (PDP)	National		National	1	3	1	2441 Warrenwille Road		Lisle	IL	60532												3108002000208002000308002000408002000508002000608002000708002000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optum.com		0	3			0					3	0	0		www.optumrx.com	www.optumrx.com
S5983	004	0	2021	29	Express Scripts Medicare - Value (PDP)	State of New York	Express Scripts Medicare - Value (PDP)	State of New York	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $445 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $445 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5983	006	0	2021	29	Express Scripts Medicare - Choice (PDP)	State of New York	Express Scripts Medicare - Choice (PDP)	State of New York	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $100.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $100.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5983	007	0	2021	29	Express Scripts Medicare - Saver (PDP)	State of New York	Express Scripts Medicare - Saver (PDP)	State of New York	1	0	0	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	www.express-scriptsmedicare.com		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $285.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $285.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5983	805	0	2021	29	Express Scripts Medicare (PDP)	Premier Performance Closed 5 Tier - Calendar	Express Scripts Medicare (PDP)	Premier Performance Closed 5 Tier - Calendar	1	3	1	PO Box 66535		ST LOUIS	MO	63166												2100000000200000000300000000400000000500000000600000000700000000	2100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.Express-ScriptsMedicare.com		0	3			0					3	0	0		www.Express-ScriptsMedicare.com	www.Express-ScriptsMedicare.com
S5805	001	0	2021	29	AARP MedicareRx Preferred (PDP)	New York		New York	1	0	0	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9108002000208002000308002000408002000508002000608002000708002000	0		0	1	0	0	1	1	4	Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicarePlans.com		0	3			0					3	0	0		www.AARPMedicarePlans.com	www.AARPMedicarePlans.com
S5805	803	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	804	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	807	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	808	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	809	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	810	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	811	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	812	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	813	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	814	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	815	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	816	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	818	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	819	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	820	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	821	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	822	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	823	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	824	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	825	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	826	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	827	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	828	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	829	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	830	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	831	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	832	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	833	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	834	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	835	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.UHCRetiree.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	836	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicareRx.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	837	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicareRx.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5805	838	0	2021	29	UnitedHealthcare MedicareRx for Groups (PDP)	National		National	1	3	1	P.O. Box 30770		Salt Lake City	UT	84130												9108002000208002000308002000408002000508002000608002000708002000	9107002200207002200307002200407002200507002200607002200707002200	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.AARPMedicareRx.com		0	3			0					3	0	0		www.UHCMedicareSolutions.com	www.UHCMedicareSolutions.com
S5877	803	0	2021	29	Alpine School District Retiree Plan (PDP)	State of Utah and State of Idaho	Alpine School District Retiree Plan (PDP)	State of Utah and State of Idaho	1	3	1	5101 South Commerce Drive		Murray	UT	84107												4000000000208002000308002000408002000508002000608002000000000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.emihealth.com		0	3			0					3	0	0		http://www.express-scripts.com	https://medicare.emihealth.com/Formulary.aspx
S5877	804	0	2021	29	Educators Mutual Retiree Plan (PDP)	State of Utah and State of Idaho	Educators Mutual Retiree Plan (PDP)	State of Utah and State of Idaho	1	3	1	5101 South Commerce Drive		Murray	UT	84107												4000000000208002000308002000408002000508002000608002000000000000	4100000000200000000300000000400000000500000000600000000700000000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.emihealth.com		0	3			0					3	0	0		http://www.express-scripts.com	https://medicare.emihealth.com/Formulary.aspx
S5904	001	0	2021	29	BlueMedicare Premier Rx (PDP)	State of Florida		State of Florida	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $405.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $405.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			1	0	0		FloridaBlue.com/medicare	MyPrime.com
S5904	002	0	2021	29	BlueMedicare Complete Rx (PDP)	State of Florida		State of Florida	1	0	0	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare		0	3			0					2	0	0		FloridaBlue.com/medicare	MyPrime.com
S5904	801	0	2021	29	BlueMedicare Group Rx (PDP)	State of Florida with National Coverage		State of Florida with National Coverage	1	3	1	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare		0	3			0					3	0	0		FloridaBlue.com/medicare	MyPrime.com
S5904	802	0	2021	29	BlueMedicare Group Rx (PDP)	State of Florida with National Coverage		State of Florida with National Coverage	1	3	1	4800 Deerwood Campus Pkwy	DCC Bldg 400 / 3rd Floor	Jacksonville	FL	32246												9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	FloridaBlue.com/medicare		0	3			0					3	0	0		FloridaBlue.com/medicare	MyPrime.com
S8182	001	0	2021	29	Amerivantage Rx Basic (PDP)	Texas		Texas	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	shop.amerigroup.com/medicare		0	3			0					3	0	0		https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
S8182	002	0	2021	29	Amerivantage Rx Enhanced (PDP)	Texas		Texas	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.amerigroup.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $340.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $340.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
S8182	003	0	2021	29	Amerivantage Rx Basic (PDP)	Arizona		Arizona	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	shop.amerigroup.com/medicare		0	3			0					3	0	0		https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
S8182	004	0	2021	29	Amerivantage Rx Enhanced (PDP)	Arizona		Arizona	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.amerigroup.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $350.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $350.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
S8182	005	0	2021	29	Amerivantage Rx Plus (PDP)	Texas		Texas	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.amerigroup.com/medicare		0	3			0					3	0	0		https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
S8182	006	0	2021	29	Amerivantage Rx Plus (PDP)	Arizona		Arizona	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												3000000000208002000308002000408002000508002000608002000000000000	3108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.amerigroup.com/medicare		0	3			0					3	0	0		https://shop.amerigroup.com/medicare	https://shop.amerigroup.com/medicare
S3375	001	0	2021	29	Blue Rx Standard (PDP)	New York		New York	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	3	Approved by Medicare	Aprobado por Medicare	0	shop.bluerxny.com/medicare		0	3			0					3	0	0		https://shop.bluerxny.com/medicare	https://shop.bluerxny.com/medicare
S3375	002	0	2021	29	Blue Rx Plus (PDP)	New York		New York	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.bluerxny.com/medicare		0	3			0					3	0	0		https://shop.bluerxny.com/medicare	https://shop.bluerxny.com/medicare
S3375	003	0	2021	29	Blue Rx Enhanced (PDP)	New York		New York	1	0	0	Enrollment Processing Center	P.O. Box 659403	San Antonio	TX	78265												2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	1		0	0	1	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	shop.bluerxny.com/medicare		0	3			0	<ul><li>This plan does not charge an annual deductible for all drugs.  The $325.00 annual deductible only applies to drugs on certain tiers.</li></ul>	<ul><li>Este plan no cobra un deducible anual para todos los medicamentos. El deducible anual de $325.00 sólo se aplica a los medicamentos en ciertos niveles.</li></ul>			3	0	0		https://shop.bluerxny.com/medicare	https://shop.bluerxny.com/medicare
S9325	001	0	2021	29	Exemplar Health Enhanced (PDP)	Entire State of North Carolina		Entire State of North Carolina	1	0	0	1107 West Market Center Drive		High Point	NC	27260		member.services@exemplarhpo.com	member.services@exemplarhpo.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.exemplar-health.com		0	3			0					3	0	0		https://www.exemplar-health.com	https://www.exemplar-health.com
S9325	002	0	2021	29	Exemplar Health Basic (PDP)	Entire State of North Carolina		Entire State of North Carolina	1	0	0	1107 West Market Center Drive		High Point	NC	27260		member.services@exemplarhpo.com	member.services@exemplarhpo.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://www.exemplar-health.com		0	3			0					3	0	0		https://www.exemplar-health.com	https://www.exemplar-health.com
S9325	003	0	2021	29	Exemplar Health Enhanced (PDP)	Entire State of Texas		Entire State of Texas	1	0	0	1107 West Market Center Drive		High Point	NC	27260		member.services@exemplarhpo.com	member.services@exemplarhpo.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	4	Approved by Medicare	Aprobado por Medicare	0	https://www.exemplar-health.com		0	3			0					3	0	0		https://www.exemplar-health.com	https://www.exemplar-health.com
S9325	004	0	2021	29	Exemplar Health Basic (PDP)	Entire State of Texas		Entire State of Texas	1	0	0	1107 West Market Center Drive		High Point	NC	27260		member.services@exemplarhpo.com	member.services@exemplarhpo.com									9000000000208002000308002000408002000508002000608002000000000000	9108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	1	2	Approved by Medicare	Aprobado por Medicare	0	https://www.exemplar-health.com		0	3			0					3	0	0		https://www.exemplar-health.com	https://www.exemplar-health.com
S2465	801	0	2021	29	Optima Medicare - Calendar Year (PDP)	Nationwide		Nationwide	1	3	1	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare		0	3			0					3	0	0		www.optimahealth.com/medicare	www.optimahealth.com/medicare
S2465	802	0	2021	29	Optima Medicare Non-Calendar Year (PDP)	Nationwide		Nationwide	1	3	1	4417 Corporation Lane		Virginia Beach	VA	23462		kemcvey@sentara.com	KRBROGAN@sentara.com									2000000000208002000308002000408002000508002000608002000000000000	2108002000208002000308002000408002000508002000608002000708002000	0		0	0	0	0	0	0		Approved by Medicare	Aprobado por Medicare	0	www.optimahealth.com/medicare		0	3			0					3	0	0		www.optimahealth.com/medicare	www.optimahealth.com/medicare