Page 171 - 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) 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

Benefits Highlights
Monthly health plan premium $7.70

Health plan deductible $750 annual deductible

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $10,000 In and Out-of-network
responsibility (does not include $5,900 In-network
prescription drugs)
Optional supplemental benefits [?] No

Additional benefits and/or reduced cost-
sharing for enrollees with certain health In-Network: Yes, contact plan for further details
conditions?
Inpatient hospital coverage
In-Network: $250 per stay
Out-of-Network: 20% per stay

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