2012 Lovelace Medicare Plan

1. 2012 Lovelace Medicare Plan Plans and benefit changes for 2012 H3251_1767 CMS 09282011

2. In 2012 Lovelace Medicare Plan will offer: • Standard Plan HMO • Enhanced Plan HMO-POS. The point-of- service (POS) option will give you the flexibility to obtain services out of network at slightly higher cost. • Medical-only HMOplan H3251_1767 CMS approved MMDDYYYY

3. LMP Standard Plan HMO $0 Any benefit not mentioned here will remain the same for 2012 H3251_1767 CMS approved MMDDYYYY

4. LMP Standard Plan HMO cont’d Any benefit not mentioned here will remain the same for 2012 H3251_1767 CMS approved MMDDYYYY

5. LMP Standard Plan HMO cont’d Any benefit not mentioned here will remain the same for 2012 H3251_1767 CMS approved MMDDYYYY

6. LMP Enhanced HMO-POS (point of service) • This product will give you the flexibility to obtain services in-network for lower cost-sharing or out-of-network (or at point-of-service) at a higher cost-sharing. • All POS services must be received from Medicare providers or at Medicare facilities and benefits only apply to Medicare-covered services. • Claims for POS services must be sent to the claims address on the back of your member ID card. The provider should not send claims to Medicare. H3251_1767 CMS approved MMDDYYYY

7. LMP Enhanced Plan HMO-POS $55.30 H3251_1767 CMS approved MMDDYYYY

8. LMP Enhanced Plan HMO-POS $55.30 cont’d H3251_1767 CMS approved MMDDYYYY

9. LMP Enhanced Plan HMO-POS Comparison H3251_1767 CMS approved MMDDYYYY

10. LMP Enhanced Plan HMO-POS comparison H3251_1767 CMS approved MMDDYYYY

11. LMP Enhanced HMO-POS (continued) • Benefits that are the same cost-sharing in and out of network: • Ambulance $75 • Emergency room $50 • Prescription drug coverage $7/36/70/33% • Routine annual physical exam $0 • Home health care $0 • Immunizations $0 H3251_1767 CMS approved MMDDYYYY

12. Benefits not available under the point-of-service feature • Benefits not offered out-of-network: • Chiropractic • Routine hearing • Routine Vision • Acupuncture • Safety Devices • Hearing aid allowance H3251_1767 CMS approved MMDDYYYY

13. LMP Medical Only - $0 premium H3251_1767 CMS approved MMDDYYYY

14. LMP Medical Only - $0 premium H3251_1767 CMS approved MMDDYYYY

15. Standard Plan HMO Prescription Drug Benefit • Deductible $0 • Initial Coverage Limit $2930 – plan price of the drug plus member copay • Coverage Gap All Tier 1 preferred generics • Catastrophic Level $4700 in out-of-pocket costs H3251_1767 CMS approved MMDDYYYY

16. Standard Plan HMO Prescription Drug Benefit H3251_1767 CMS approved MMDDYYYY

17. Enhanced Plan HMO-POS Prescription Drug Benefit • Deductible $0 • Initial Coverage Limit $4000 – plan price of the drug plus member copay • Coverage Gap All Tier 1 preferred generics • Catastrophic Level $4700 in out-of-pocket costs H3251_1767 CMS approved MMDDYYYY

18. Enhanced Plan HMO-POS Prescription Drug Benefit H3251_1767 CMS approved MMDDYYYY

19. Prescription Discount • Once you reach the “coverage gap” on your plan, you will receive a 50% discount on brand drugs. H3251_1767 CMS approved MMDDYYYY

20. Savings Programs! • Get help with your Medicare out-of-pocket prescription expenses, Medicare premiums, and more. • Limited Income Subsidy (LIS) Part D Extra Help • Medicare provides “extra help” to pay prescription drug costs for people who meet specific income and resource limits. • Medicare Savings Programs • New Mexico offers programs that could pay your Medicare Part B • CALL SOCIAL SERVICES COORDINATORS • 1-866-706-6874 H3251_1767 CMS approved MMDDYYYY

21. Election/Enrollment Periods • Annual Election Period (AEP) October 15, 2011 through December 31, 2011 for effective date of January 1, 2012. • In 2012 there will NOT be an opportunity to change between LMP Standard and LMP Enhanced plans (no Open Enrollment Period). H3251_1767 CMS approved MMDDYYYY

22. Election/Enrollment Periods (continued) • January 1 through February 14, 2012 you can only disenroll and return to Original Medicare • REMEMBER: October 15 through December 7, 2011. H3251_1767 CMS approved MMDDYYYY

23. Election/Enrollment Periods (continued) • If you wish to remain on your current plan with 2012 benefits, there is not need to do anything. • If you wish to change from the Standard HMO to the Enhanced HMO-POS or vice versa, you must complete and return the 2012 plan Selection Form which is in your Annual Notice of Change (ANOC) packet. H3251_1767 CMS approved MMDDYYYY

24. Election/Enrollment Periods (continued) • If you wish to change to the Medical-only HMO plan because you prefer to get your prescriptions through the VA or Tricare, please complete and return the 2012 Plan Selection Form which is in your Annual Notice of Change (ANOC) packet. After that you will be sent a new enrollment form to complete. • If you sign-up with another Medicare Advantage company or a stand-alone PDP you will automatically be disenrolled from LMP. H3251_1767 CMS approved MMDDYYYY

25. Be sure to visit our website. You can view all plan documents, the current formulary and search the most current provider plan finderwww.lovelacemedicareplan.com • Customer Care Center • 1-855-730-LOVE (5683) • TTY/TTD 711 • Hours of Operation are seven days a week from 8:00 am to 8:00 pm H3251_1767 CMS approved MMDDYYYY

26. Disclaimers:The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.Individuals must have both Part A and Part B to enroll.You must continue to pay your Part B premiumYou may only enroll in the plan during specific times of the year. Contact Lovelace Senior Plan for more information.People with limited incomes may qualify for Extra Help to pay for their prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week, TTY users should call 1-877-486-2048.This information is available in a different format, including Spanish and large print. Please call Customer Care at the number listed above if you need plan information in another format or language.Esta información esta a su disposición en diferentes formatos, incluso en español y en letras mas grandes. Sírvase llamar al Centro de Atención a los Clientes al 505-727-5400 o al 1-800-808-7363; para la línea telefónica TTY/TDD llame al 711, si usted necesita recibir la información sobre el plan en algún otro formato. H3251_1767 CMS approved MMDDYYYY