Boone

Calhoun

Callaway

Cole

Franklin

Gasconade

Jefferson

JerseyLincoln

Madison

Miller

Moniteau

Monroe

Montgomery

Osage

St. Charles

St. Clair

St. Louis St. Louis City

WarrenWarren

MissouriIllinois

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

PRODUCTS

MEDICARE ELIGIBLES

AVAILABILITY

HMO, HMO-POS and PPO plan options

450,000 Medicare Eligibles in the service area

Group Health Plan: Medicare Advantage

Advantra 1,2 & Gold:Missouri Counties – Boone*, Callaway, Cole, Franklin, Gascon-ade, Jefferson, Lincoln, Miller, Moniteau, Osage, Montgomery, St. Charles, St. Louis, St. Louis City and WarrenIllinois Counties – Calhoun, Jersey, Madison, Monroe and St. Clair

Advantra PPO:St. Louis County, St. Louis City, St. Charles County, Lincoln County, Warren County, Franklin County, Jefferson County

Coventry is the low-cost, CMS 4-Star rated plan that Medicare benefi ciaries rely on. All of our plans include Part D prescription drug coverage; plus, as a local plan, we have one of the largest provider networks in the area — so your clients can choose what’s right for them.

Illinois, Missouri

Wide choice of physicians, specialists and hospitals

Free health club membership

NEW for

2012!

Lower MOOP'sLower Hospital co-paysDental benefits included

*Gold Advantage Opt 1 (HMO) NOT available in Boone County.

NETWORK HIGHLIGHTS/PRODUCT STRENGTHS & BENEFITS

A large network of doctors and facilities you know and trust, including BJC, Washington University physicians & specialists, and Capital Regional/University of Missouri Hospitals

Missouri

St. LouisSt. Louis City

St. Charles

Lincoln

Warren

Franklin

Jefferson

Missouri

St. LouisSt. Louis City

St. Charles

Lincoln

Warren

Franklin

Jefferson

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

PRODUCT(S)

MEDICARE ELIGIBLES

AVAILABILITY

HMO/HMO-POS/PPO Medicare Advantage plans from CHC of Missouri

321,472 Medicare Eligibles in the service area

Gold Advantage Opt. 2 (HMO), Advantra PPO:St. Louis County, St. Louis City, St. Charles County, Lincoln County, Warren County, Franklin County, Jefferson County

Total Care (HMO-POS)St. Louis County, St. Louis City, St. Charles County

Set your

ON SUCCESSSIGHTS

SS

Missouri

CHC of Missouri: 2012 Medicare Advantage

CHC of Missouri is the low-cost, CMS 4-Star rated plan that Medicare benefi ciaries rely on. All of our plans include Part D prescription drug coverage; plus, as a local plan, we have one of the largest provider networks in the area — so your clients can choose what’s right for them.

Wide choice of physicians, specialists and hospitals Free health club membership

PRODUCT STRENGTHS & BENEFITS

NEW for

2012!New lower MOOP'sNew lower Hospital co-paysNew! Dental benefits included

Set your

ON SUCCESSSIGHTS

SS

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

Missouri

Advantra (PPO) Gold Advantage Option II(HMO)

Total Care(HMO - POS)

Monthly Premium $20 $0 $0

Annual Deductible $750 IN/$1,250 OON $0 $0

Maximum Out-of-Pocket $3,200 IN/$5,100 Combined IN & OON $4,500 $2,700 IN/Unlimited OON

Prescription DrugsTier 1Tier 2Tier 3Tier 4

Yes$5 copay

$45 copay$80 copay

33% coinsurance

Yes$5 copay$45 copay$80 copay

33% coinsurance

Yes$3 copay

$45 copay$80 copay

33% coinsurance

Medicare Covered Services

PCP visit $15 copay IN/30% OON $20 copay $5 copay IN/30% OON

Specialist visit $30 copay IN/30% OON $40 copay $30 copay IN/30% OON

Chiropractor visit $20 copay IN/30% OON $20 copay $20 copay IN/30% OON

Lab $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Emergency Room $65 copay $65 copay $65 copay

Hospitalization $200/day, days 1-5 IN/30% per stay OON $175/day, days 1-10 $220/day, days 1-10 IN/30%

per stay OON

Skilled Nursing Facility$0/day, days 1-20,

$100/day, days 21-52;30% per stay OON

$50/day days 1-20, $100/day days 21-55

$0/day, days 1-10,$100/day, days 11-37;

30% per stay OON

Cardiac Rehab Services $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Pulmonary Rehab Services $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Medicare Covered Preventive Services $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Services Not Covered by Original Medicare

Fitness Program Yes Yes Yes

Transportation no coverage $0 copay for 24 one-way trips $0 copay for 24 one-way trips

Routine Eye Exam $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Eye Glasses $15 copay/ $100 allowance IN/ $100 allowance OON $15 copay/ $100 allowance $15 copay/ $100 allowance

IN/$100 allowance OON

Dental (Preventive) no coverage$0 copay, 1 oral exam,

1 cleaning, 1 x-ray IN/No coverage OON

no coverage

CHC of Missouri: 2012 Medicare Advantage

Boone

Calhoun

Callaway

Cole

Franklin

Gasconade

Jefferson

JerseyLincoln

Madison

Miller

Moniteau

Monroe

Montgomery

Osage

St. Charles

St. Clair

St. Louis St. Louis City

WarrenWarren

MissouriIllinois

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

PRODUCT(S)

MEDICARE ELIGIBLES

AVAILABILITY

Advantra Opt. 1 (HMO), Advantra Opt. 2 (HMO-POS), Gold Advantage Opt. 1 (HMO) plans from CHC of Missouri

450,000 Medicare Eligibles in the service area

CHC of Missouri: 2012 Medicare Advantage

Missouri Counties – Boone*, Callaway, Cole, Franklin, Gasconade, Jefferson, Lincoln, Miller, Moniteau, Osage, Montgomery, St. Charles, St. Louis, St. Louis City and Warren

Illinois Counties – Calhoun, Jersey, Madison, Monroe and St. Clair

Set your

ON SUCCESSSIGHTS

SSCHC of Missouri is the low-cost, CMS 4-Star rated plan that Medicare benefi ciaries rely on. All of our plans include Part D prescription drug coverage; plus, as a local plan, we have one of the largest provider networks in the area — so your clients can choose what’s right for them.

Illinois, Missouri

Wide choice of physicians, specialists and hospitals Free health club membership

PRODUCT STRENGTHS & BENEFITS

NEW for

2012!New lower MOOP'sNew lower Hospital co-paysNew! Dental benefits included

*Gold Advantage Opt 1 (HMO) NOT available in Boone County.

Illinois, Missouri

Set your

ON SUCCESSSIGHTS

SS

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

Advantra Option 1(HMO)

Advantra Option 2(HMO-POS)

Gold Advantage Option 1(HMO)

Monthly Premium $22 $88 $0

Annual Deductible None None None

Maximum Out-of-Pocket $3,400 $2,700 IN/Unlimited OON $2,700

Prescription DrugsTier 1Tier 2Tier 3Tier 4

Yes$5 copay

$40 copay$80 copay

33% coinsurance

Yes$5 copay

$40 copay$80 copay

33% coinsurance

Yes$2 copay

$40 copay$80 copay

33% coinsurance

Medicare Covered Services

PCP visit $20 copay $10 copay IN/30% OON $10 copay

Specialist visit $45 copay $10 copay IN/30% OON $30 copay

Chiropractor visit $20 copay $20 copay IN/30% OON $20 copay

Lab $0 copay $0 copay IN/30% OON $0 copay

Emergency Room $65 copay $65 copay $65 copay

Hospitalization $220/day, days 1-10 $220/day, days 1-10 IN/30% per stay OON $220/day, days 1-10

Skilled Nursing Facility $0/day days 1-7, $100/day days 8-41

$0/day days 1-15,$100/day days 16-42;

30% per stay OON

$0/day, days 1-15,$100/day, days 16-42

Cardiac Rehab Services $0 copay $0 copay IN/30% OON $0 copay

Pulmonary Rehab Services $0 copay $0 copay IN/30% OON $0 copay

Medicare Covered Preventive Services $0 copay $0 copay IN/30% OON $0 copay

Services Not Covered by Original Medicare

Fitness Program Yes Yes Yes

Transportation $0 for 24 One way trips $0 for 24 One way trips $0 for 24 One way trips

Routine Eye Exam $0 copay $0 copay IN/30% OON $0 copay

Eye Glasses $15 copay/ $100 allowance $15 copay/ $100 allowance IN/$100 allowance OON $15 copay/ $100 allowance

Dental (Preventive) $0 copay, 1 oral exam, 1 cleaning, 1 x-ray

$0 copay, 1 oral exam, 1 cleaning, 1 x-ray

$0 copay, 1 oral exam,1 cleaning, 1 x-ray

CHC of Missouri: 2012 Medicare Advantage

Illinois, Missouri

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

Advantra Option 1(HMO)

Advantra Option 2(HMO-POS)

Gold Advantage Option 1(HMO) Advantra (PPO)

Monthly Premium $22 $88 $0 $20

Annual Deductible None None None $750 IN/$1,250 OON

Maximum Out-of-Pocket $3,400 $2,700 IN/Unlimited OON $2,700 $3,200 IN/$5,100 Combined IN & OON

Prescription DrugsTier 1Tier 2Tier 3Tier 4

$5 copay$40 copay$80 copay

33% coinsurance

$5 copay$40 copay$80 copay

33% coinsurance

$2 copay$40 copay$80 copay

33% coinsurance

$5 copay$45 copay$80 copay

33% coinsurance

Medicare Covered Services

PCP Visit $20 copay $10 copay IN/30% OON $10 copay $15 copay IN/30% OON

Specialist Visit $45 copay $25 copay IN/30% OON $30 copay $30 copay IN/30% OON

Chiropractor Visit $20 copay $20 copay IN/30% OON $20 copay $20 copay IN/30% OON

Lab $0 copay $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Emergency Room $65 copay $65 copay $65 copay $65 copay

Hospitalization $220/day, days 1-10$220/day, days 1-10

IN/30% per stay OON

$220/day, days 1-10 $200/day, days 1-5 IN/30% per stay OON

Skilled Nursing Facility $0/day days 1-7, $100/day days 8-41

$0/day days 1-15,$100/day days 16-42;

30% per stay OON

$0/day, days 1-15,$100/day, days 16-42

$0/day, days 1-20,$100/day, days 21-52;

30% per stay OON

Cardiac Rehab Services $0 copay $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Pulmonary Rehab Services $0 copay $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Medicare Covered Preventive Services $0 copay $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Services Not Covered by Original Medicare

Fitness Program Yes Yes Yes Yes

Transportation $0 for 24 One way trips $0 for 24 One way trips $0 for 24 One way trips no coverage

Routine Eye Exam $0 copay $0 copay IN/30% OON $0 copay $0 copay IN/30% OON

Eye Glasses $15 copay/ $100 allowance $15 copay/ $100 allowance IN/$100 allowance OON $15 copay/ $100 allowance

$15 copay/ $100 allowance IN/ $100

allowance OON

Dental (Preventive) $0 copay, 1 oral exam, 1 cleaning, 1 X-ray

$0 copay, 1 oral exam, 1 cleaning, 1 X-ray

$0 copay, 1 oral exam,1 cleaning, 1 X-ray no coverage

Group Health Plan: Medicare Advantage

Boone

Brown

Champaign

Coles

Douglas

Marshall

McLean

Moultrie

Ogle

Peoria

Piatt

Sangamon

Stark

Stephenson

Tazewell

Vermilion

Winnebago

WoodfordWoodford

Adams

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

PRODUCTS

MEDICARE ELIGIBLES

AVAILABILITY

HMO and PPO plan options

262,869 Medicare Eligibles in the Coventry service area

PERSONALCARE: Medicare Advantage

Adams, Boone, Brown, Champaign, Coles, Douglas, Marshall, McLean, Moultrie, Ogle, Peoria, Piatt, Sangamon, Stark, Stephenson, Tazewell, Winnebago, Woodford, Vermillion

As a CMS 4-star rated, locally run plan, Coventry is focused on providing your clients with personal attention and service as we work with Medicare benefi ciares, and their doctors, to protect both their health and their fi nancial security.

Illinois

Low copays for prescription drugs Low physician copays $0 deductible

NEW for

2012!Advantra Total Care (HMO) partnership with SwedishAmerican available in Winnebago and Boone counties - offers $0 premium with $5 PCP copaysEnhanced benefits include Dental, Vision and FitnessAdvantra Silver offers lower physician copays and maximum out-of-pocket protection than 2011.

NETWORK HIGHLIGHTS/PRODUCT STRENGTHS & BENEFITS

Advantra Silver - Rockford area: SwedishAmerican, Rockford Memorial; Peoria area: Methodist Medical Ctr., Proctor, Pekin Memorial, BroMenn; Champaign area: Provena, Carle Hospital, Christie ClinicPhysicians; Springfi eld/Quincy area: St. John's, Memorial Medical, Blessing Hospital Advantra Total Care - SwedishAmerican

For broker use only. Not for distribution to benefi ciaries. Coventry data classifi cation: internal use only.Plan benefi ts may vary by county. Benefi ts and pricing are not fi nal until CMS approved.

Illinois

Advantra Silver (PPO)

Advantra Total Care (HMO)in partnership with

PersonalCare and SwedishAmerica(available in Boone and Winnebago only)

Monthly Premium $13 $0

Deductible $0 $0

Maximum Out-of-Pocket $3,400 IN-NET, $5,100 In-and-out-of-net comp $3,400

Prescription Drugs Tier 1 Tier 2 Tier 3 Tier 4

$5 copay$40 copay$80 copay

33% coinsurance

$5 copay$40 copay$79 copay

33% coinsurance

Medicare Covered Services

Inpatient Hospital $180 copay per day for days 1-10 $0 copay for days 11-90

$175 copay per day for days 1-10 $0 copay for days 11-90

SNF $0 copay for days 1-20 $117 copay per day for days 21-49

$0 copay for days 1-20 $100 copay per day for days 21-54

PCP Visit $10 copay $5 copay

Specialist Visit $35 copay $25 copay

Outpatient Surgery 20% coinsurance 20% coinsurance

Emergency Room $65 copay $65 copay

Diabetic Supplies 20% coinsurance $0 copay

Preventive Services

Annual Physical Exams $0 copay $0 copay

Bone Mass Measurements $0 copay $0 copay

Colorectal Screening Exams $0 copay $0 copay

Immunizations $0 copay $0 copay

Screening Mammograms $0 copay $0 copay

GYN Exams $0 copay $0 copay

Prostate Screening Exams $0 copay $0 copay

Services Not Covered by Original Medicare

Dental Services $0 (Basic Dental) $0 (Basic Dental)

Vision Services $0 for Vision Exam $0 for Vision Exam

Worldwide urgent/Emergency Care Included Included

Fitness Program Silver & Fit Silver & Fit

PERSONALCARE: Medicare Advantage