Page 169 - Cover Letter and Evaluation for Sue Marx

2/7/2019 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 15206
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 1859577088
and more coverage and star ratings.
Password Date: 02/05/2019
Important Coverage Information

Symbols

A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage

* Estimated

Advantra Gold (PPO) PO Box 7087 Overall Star Rating: Enroll
London, KY 40742 Members: 1- [?]
(H5522-001-0) 1 800-290-0190 711 (TTY/TDD)
Non Members: 1-855-275-6627 4 out of 5 stars
Organization: Coventry Health Care 711 (TTY/TDD)
Plan Type: Local Preferred
Provider Organization

Additional Plan Information

Overall Star Rating [?] 4 out of 5 stars

Health Plan Star Ratings [?] 4 out of 5 stars

Drug Plan Star Ratings [?] 4.5 out of 5 stars

Plan Type: Local Preferred Provider Organization
Plan Status: Approved by Medicare
Area: Allegheny County

View plan website 
Important Note:
This plan's deductible only applies to out-of-network services.

View Drug Benefit Summary

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5522&plnid=001&sgmntid=0 1/2