Introduction to the Summary of Benefits for
Network PlatinumPlus Pharmacy

January 1, 2008 – December 31, 2008
This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please review the Evidence of Coverage.

You have choices in health care.
As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan.  Another option is a Medicare health plan, like Network PlatinumPlus Pharmacy. You may have other options, too.  You make the choice.  No matter what you decide, you are still in the Medicare program.

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You may be able to join or leave a plan only at certain times. Please call Network PlatinumPlus Pharmacy Customer Service or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048.

Comparing your options
You can compare Network PlatinumPlus Pharmacy and the Original Medicare Plan using this Summary of Benefits Chart. The charts in the Summary list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer additional benefits, which may change from year to year.

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The Network PlatinumPlus Pharmacy service area
The service area for this plan includes: Brown, Calumet, Dodge, Fond du Lac, Green Lake, Manitowoc, Marquette, Outagamie, Portage, Sheboygan, Waupaca, Waushara and Winnebago counties. You must live in one of these places to join the plan. Visit our Service Area Map.

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Choosing a doctor
Network PlatinumPlus Pharmacy has formed a network of doctors, specialists and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside our network. The health providers in our network can change at any time. Please see the Provider Directory for an up-to-date list of doctors in our network.

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Out-of-network care
You can go to doctors, specialists or hospitals out-of-network, too.  You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in- and/or out-of-network in order for Network PlatinumPlus Pharmacy to pay for these services. For more information, please call Customer Service.

Our pharmacy network
Network PlatinumPlus Pharmacy has formed a network of pharmacies. You can use any pharmacy in our network. The pharmacies in our network can change at any time. Click here to view our Pharmacy Directory.

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Filling your prescriptions out-of-network
If you go to a pharmacy that’s not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under our plan. For more information, call Customer Service or review our Pharmacy Directory Introduction.

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Medicare Part B or Part D drugs
Network PlatinumPlus Pharmacy covers both Medicare Part B and Part D prescription drugs.

The following outpatient prescription drugs may be covered under Medicare Part B. This may include, but not be limited to, the following types of drugs:

• Some antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
  
• Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
  
• Erythropoietin (Epoetin alpha or Epogen^®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
  
• Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
  
• Injectable Drugs: Most injectable drugs administered incident to a physician’s service.
  
• Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.
  
• Some Oral Cancer Drugs: If the same drug is available in injectable form.
  
• Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapy regimen. Inhalation and infusion drugs provided through DME.

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The Formulary
Network PlatinumPlus Pharmacy uses a Formulary.  A Formulary is a preferred list of drugs selected to meet patient needs. The plan may periodically make changes to the Formulary.  If the Formulary changes, affected enrollees will be notified, in writing, before the change is made. See the Formulary Directory Introduction for more details.

Medication therapy management (MTM)
A medication therapy management (MTM) program is a benefit that your plan may offer.  You may be identified to participate in a program designed for your specific health and pharmacy needs. It is recommended that you take full advantage of this covered benefit if you are selected. Contact Network PlatinumPlus Pharmacy Customer Service or click here for more information.

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Your plan protections
All health plans in the Medicare program agree to stay with the program for a full year at a time. Each year, the plans decide whether to continue for another year.  Even if a Medicare health plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for health care coverage in your area and give you information about your right to get Medicare supplemental insurance coverage. You can choose another health plan if one is available, or you can receive care from the Original Medicare Plan.

If Network PlatinumPlus Pharmacy ever denies your claim or a service, we will explain our decision to you. You always have the right to appeal and ask us to review the claim or service that was denied.  If a decision is not made in your favor, your appeal will be reviewed by an independent organization that works for Medicare. Please see the Evidence of Coverage for more information.

Please call Network PlatinumPlus Pharmacy for more information about this plan.

Customer Service hours:
Monday, Wednesday, Thursday, Friday
8 a.m. – 5 p.m. Central
Tuesday 8 a.m. – 4 p.m. Central

Current members should call 1–800–378–5234. (TTY/TDD 1–800–947–3529)
Prospective members should call 1–800-983–7587. (TTY/TDD 1–800–947–3529)

For more information about Medicare, call 1-800-MEDICARE (1–800–633–4227) (TTY/TDD users should call 1–800–486–2048), or visit www.medicare.gov for more information about Medicare.  If you have special needs, this document may be available in other formats.