Blue Medicare Advantage PPO Contracted Providers

Transcription

1 Appendix D Blue Medicare Advantage PPO Contracted Providers Ambulatory Surgicenters... 2 Durable Medical Equipment... 4 Hearing Aid 6 Home Health Care.. 7 Home Infusion 10 Hospice Inpatient Metro Hospitals 12 Mental Health 15 Orthotic & Prosthetic. 16 Hospital Based Outpatient Surgery 18 Renal Dialysis 20 Skilled Nursing Facilities.. 26 Rev.03/13/2018 Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER SURGICENTER 10/1/17 ADVANCED AMBULATORY SURG CTR INC 2333 N HARLEM AVE CHICAGO IL (773) A 12/1/17 SURGICENTER 7/1/17 ADVOCATE SURGERY CTR LIBERTYVILLE 825 S MILWAUKEE AVE LIBERTYVILLE IL (224) A 2/1/18 SURGICENTER 2/1/17 AIDEN CENTER FOR DAY SURGERY 1580 W LAKE ST ADDISON IL (630) A 2/1/17 SURGICENTER 5/1/16 APOLLO SURGICAL CENTER LLC 2750 S RIVER RD DES PLAINES IL (847) A 6/1/16 SURGICENTER 2/1/17 ASHTON SURGICAL CENTER 1800 MCDONOUGH RD HOFFMAN ESTATES IL (847) A 2/1/17 SURGICENTER 11/1/17 ASSOCIATED SURGICAL CENTER LLC 129 W RAND RD ARLINGTON HEIGHTS IL (847) A 2/1/18 SURGICENTER 9/1/16 CENTER FOR RECONSTRUCTIVE SURGERY 6311 W 95TH ST OAK LAWN IL (708) A 10/1/16 SURGICENTER 6/1/16 CHICAGO PROSTATE CANCER SURG CTR 815 PASQUINELLI DR WESTMONT IL (630) A 11/1/16 SURGICENTER 4/1/15 DUPAGE EYE SURGERY CENTER LLC 2015 N MAIN ST WHEATON IL (630) SURGICENTER 2/1/16 ELMHURST OUTPATIENT SURGERY CTR 1200 S YORK RD ELMHURST IL (630) SURGICENTER 10/1/16 EYE SURGERY CENTER OF HINSDALE 950 N YORK RD HINSDALE IL (630) A 11/1/16 SURGICENTER 6/1/16 FULLERTON SURGERY CENTER 4849 W FULLERTON AVE CHICAGO IL (773) A 6/1/16 SURGICENTER 5/1/15 GLEN ENDOSCOPY CENTER LLC 2551 COMPASS RD GLENVIEW IL (800) SURGICENTER 10/1/15 GOLF SURGICAL CENTER 8901 GOLF RD DES PLAINES IL (847) SURGICENTER 5/1/15 HOFFMAN ESTATES SURGERY CNTR LLC 1555 BARRINGTON RD HOFFMAN ESTATES IL (847) SURGICENTER 1/1/18 IL SPORTS MED AND ORTHO SURG CTR 9000 WAUKEGAN RD MORTON GROVE IL (847) A 2/1/18 SURGICENTER 8/1/16 KENDALL POINT SURGERY CNTR 100 W FIFTH ST OSWEGO IL (630) A 10/1/16 SURGICENTER 1/1/17 LOYOLA AMBULATORY SURGERY CENTER 1S224 SUMMIT AVE OAKBROOK TERRACE IL (630) A 2/1/17 SURGICENTER 7/1/15 MIDWEST CENTER FOR DAY SURGERY 3811 HIGHLAND AVE DOWNERS GROVE IL (630) SURGICENTER 7/1/15 NAPERVILLE SURGICAL CENTRE LLC 1263 RICKERT DR NAPERVILLE IL (630) SURGICENTER 1/1/15 NORTHWEST COMM DAY SURG CTR II 675 W KIRCHHOFF RD ARLINGTON HEIGHTS IL (847) SURGICENTER 1/1/17 NORTHWEST SURGICARE LTD 1100 W CENTRAL RD ARLINGTON HEIGHTS IL (847) A 2/1/17 SURGICENTER 9/1/16 NOVA MED SURGERY OF CHICAGO 3034 W PETERSON AVE CHICAGO IL (773) A 10/1/16 SURGICENTER 2/1/17 OAK BROOK SURGICAL CENTER 2425 W 22ND ST OAK BROOK IL (630) A 2/1/17 SURGICENTER 5/1/15 OAK LAWN ENDOSCOPY 9921 SOUTHWEST HIGHWAY OAK LAWN IL (708) SURGICENTER 7/1/15 PALOS HILLS SURGERY CENTER LLC S ROBERTS RD PALOS HILLS IL (708) SURGICENTER 10/1/15 PALOS SURGI CENTER LLC 7340 COLLEGE DR PALOS HEIGHTS IL (708) SURGICENTER 5/1/16 RAVINE WAY SURGERY CENTER LLC 2350 RAVINE WAY GLENVIEW IL (847) A 10/1/16 SURGICENTER 1/1/17 RUSH COPLEY SURGICENTER LLC 2111 OGDEN AVENUE AURORA IL (630) A SURGICENTER 10/1/16 SOUTHWEST SURGERY CENTER LLC CNTR DARVIN DR MOKENA IL (708) SURGICENTER 8/1/16 SOUTHWESTERN MEDICAL CTR LLC 7456 S STATE ROAD BEDFORD PARK IL (773) A 10/1/16 SURGICENTER 1/1/17 THE CENTER FOR SURGERY 475 E DIEHL RD NAPERVILLE IL (630) A 2/1/17 SURGICENTER 5/1/15 THE LAKE BLUFF IL ENDOSCOPY ASC 101 S WAUKEGAN RD LAKE BLUFF IL (847) SURGICENTER 7/1/15 TINLEY WOODS SURGERY CENTER S LAGRANGE RD TINLEY PARK IL (708) SURGICENTER 8/1/15 TRI CITIES SURGERY CENTER LLC 345 DELNOR DR GENEVA IL (630) SURGICENTER 5/1/16 UNITED SHOCKWAVE SERVICES LTD 120 N LAGRANGE RD LAGRANGE IL (708) A 8/1/16 SURGICENTER 8/1/16 VALLEY AMBULATORY SURGERY CENTER 2210 DEAN ST ST CHARLES IL (630) A 9/1/16 SURGICENTER 10/1/17 WINCHESTER ENDOSCOPY 1870 W WINCHESTER RD LIBERTYVILLE IL (224) A 11/1/17 s: A: New C: 2

3 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 3

4 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER DME 9/1/16 A TO Z MOBILITY AND MED EQUIP W INDUSTRIAL DR N PLAINFIELD IL (779) DME 8/1/16 AAMS SUPPLY CHICAGO INC 6433 N CALIFORNIA AVE CHICAGO IL (773) DME 8/1/16 AAMS SUPPLY CHICAGO INC 6433 N CALIFORNIA AVE CHICAGO IL (773) A DME 1/1/14 APRIA HEALTHCARE INC 1015 W DEITWEILLER DR PEORIA IL (309) DME 3/1/16 APRIA HEALTHCARE INC 1015 W DEITWEILLER DR PEORIA IL (309) DME 8/1/15 ARMOR MED SUPPLY LLC CHCAGO SOUTH S KEDZIE MARKHAM IL (708) DME 9/1/15 BASINGERS PHARMACY 2130 W JEFFERSON ST JOLIET IL (815) DME 12/1/16 BLI MEDICAL SUPPLY LTD 7737 S WESTERN AVE CHICAGO IL (773) A DME 1/1/14 BYRAM HEALTHCARE INC 3010 WOODCREEK DR DOWNERS GROVE IL (800) DME 1/1/17 CENTEGRA HOME MEDICAL EQUIPMENT 213 N FRONT ST MCHENRY IL (815) DME 5/1/16 COMPLIANT SLEEP SOLUTIONS CONVERG 7501 LEMONT RD WOODRIDGE IL (630) A 6/1/16 DME 2/1/16 DJ O LLC 599 CARDIGAN RD SAINT PAUL MN (800) DME 1/1/14 DOUBEK MEDICAL SUPPLY INC S CICERO AVE ALSIP IL (708) DME 8/1/15 EMPI INC 599 CARDIGAN RD SAINT PAUL MN (800) DME 8/1/15 FITZSIMMONS SURGICAL SUPPLY 8000 W 186TH ST TINLEY PARK IL (708) DME 12/1/16 HAYAT HOME MEDICAL EQUIPMENT 3518 W 95TH ST EVERGREEN PARK IL (708) A DME 9/1/15 HEALTH TECHNOLOGY RESOURCES 1400 E LAKE COOK RD BUFFALO GROVE IL (847) DME 1/1/17 HEARTLAND HOME MEDICAL SUPPLY 716 E EMPIRE ST BLOOMINGTON IL (309) DME 1/1/15 HOVEROUND CORPORATION 241 S FRONTAGE RD BURR RIDGE IL (800) DME 9/1/15 ILLINOIS SLEEP PROVIDER 8736 W OGDEN AVE LYONS IL (708) DME 1/1/17 INDEPENDENCE PLUS INC 720 ENTERPRISE DR OAK BROOK IL (630) A 7/1/17 DME 6/1/16 INFUSYSTEM INC 350 S NORTHWEST HWY PARK RIDGE IL (800) DME 6/1/16 INFUSYSTEM INC 600 JOHN DEERE RD MOLINE IL (800) DME 3/1/16 LEHAN DRUG INC 1407 S 4TH ST DEKALB IL (815) DME 1/1/14 LINCARE INC 1701 HOWARD ST ELK GROVE VILLAGE IL (847) DME 1/1/14 LINCARE INC 700 N HENERIETTA ST EFFINGHAM IL (217) DME 1/1/14 MARK DRUG 548A W DUNDEE RD WHEELING IL (847) DME 3/1/17 MARS MEDICAL EQUIPMENT SUPPLY 333 W MAPLE ST NEW LENOX IL (708) A 7/1/17 DME 8/1/15 MCKESSON PATIENT CARE SOLUTIONS 140 EXCHANGE BLVD GLENDALE HEIGHTS IL (856) DME 1/1/17 MED SOURCE LLC 3002 GILL ST BLOOMINGTON IL (309) DME 5/1/16 MEDLINE INDUSTRIES INC 1 MEDLINE PL MUNDELEIN IL (866) A 8/1/16 DME 10/1/17 MEDSERV EQUIPMENT CORP N RAND RD PALATINE IL (847) A 2/1/18 DME 1/1/17 MEDSOURCE LLC 700 N SACRAMENTO BLVD CHICAGO IL (888) A DME 8/1/15 MERIT SLEEP TECHNOLOGIES INC 1300 S MAIN ST LOMBARD IL (630) DME 5/1/15 MINI MED DIST CORP TH AVE SCHILLER PARK IL (800) DME 1/1/15 MOBILITY SYSTEMS SOLUTIONS INC 9755 S 78TH AVE HICKORY HILLS IL (708) DME 2/1/15 NATIONAL SEATING AND MOBILITY INC S RIDGELAND AVE ALSIP IL (708) DME 2/1/15 NATIONAL SEATING AND MOBILITY INC 4209 PFIEFFER RD BARTONVILLE IL (866) DME 1/1/17 NATIONAL SEATING AND MOBILITY INC S 76TH AVENUE BRIDGEVIEW IL (844) A DME 2/1/15 NATIONAL SEATING AND MOBILITY INC 3808 W SPRINGFIELD AVE CHAMPAIGN IL (217) DME 2/1/15 NATIONAL SEATING AND MOBILITY INC 85 EISENHOWER LN SOUTH LOMBARD IL (630) DME 8/1/17 NATIONWIDE MEDICAL EQUIPMENT 3301 W 63RD ST CHICAGO IL (773) A 12/1/17 DME 8/1/16 OPTION HEALTH LTD 985 AVE OF THE CITIES SILVIS IL (309) A 9/1/16 DME 1/1/16 ORBIT MED OF NAPERVILLE INC 1701 QUINCY AVE NAPERVILLE IL (630) DME 1/1/16 ORBIT MEDICAL OF CHICAGO INC 1419 W CARROLL AVE CHICAGO IL (866) DME 12/1/15 ORTHOFIX INC 875 N MICHIGAN AVE CHICAGO IL (800)

5 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER DME 11/1/17 OTTO BOCK ORTHOPEDIC SERVICES LLC 467 W FULLERTON AVE ELMHURST IL (800) A DME 6/1/16 PACIFIC PULMONARY SERVICES 2201 W TOWNLINE RD PEORIA IL (309) A 8/1/16 DME 6/1/16 PACIFIC PULMONARY SERVICES 3384 N PUBLISHERS ROCKFORD IL (815) A 8/1/16 DME 6/1/16 PACIFIC PULMONARY SERVICES 9935 S 76TH AVE BRIDGEVIEW IL (708) A 8/1/16 DME 6/1/16 PACIFIC PULMONARY SERVICES 4511 N KEDZIE AVE CHICAGO IL (773) A 8/1/16 DME 6/1/16 PACIFIC PULMONARY SERVICES 1521 WRIGHT BLVD SCHAUMBURG IL (847) A 8/1/16 DME 6/1/16 PACIFIC PULMONARY SERVICES 1551 E 91ST DR MERRILLVILLE IN (219) A 8/1/16 DME 2/1/15 PATIENTS CHOICE 625 W UNIVERSITY DR ARLINGTON HEIGHTS IL (847) DME 1/1/16 PREMIER MEDICAL PRODUCTS INC 1701 QUINCY AVE NAPERVILLE IL (630) DME 1/1/14 REHABTECH SUPPLY CORPORATION 655 W GRAND AVE ELMHURST IL (888) DME 1/1/14 RGH ENTERPRISES INC DBA EDGEPARK 1360 MADELINE LN ELGIN IL (800) DME 1/1/17 RIVERSIDE HEALTH EQUIPMENT 44 MEADOWVIEW CENTER KANKAKEE IL (815) A 9/1/17 DME 8/1/16 SIGMA SURGICAL SUPPLY CORP 2708 W DIVISION CHICAGO IL (773) DME 5/1/16 SIONA HEALTH CARE PRODUCTS INC 5011 N LINCOLN AVE CHICAGO IL (773) A 6/1/16 DME 1/1/15 SLEEP RX LLC 7536 N ST LOUIS SKOKIE IL (847) DME 8/1/15 SLEEPMED THERAPIES INC 2357 HASSELL ROAD HOFFMAN ESTATES IL (847) DME 8/22/16 THH ACQUISITION LLC I 1701 N RANDALL ROAD ELGIN IL (847) A 11/1/16 DME 5/1/15 THH ACQUISITION LLC I 780 S MCLEAN BLVD ELGIN IL (847) DME 1/1/14 UNITED SEATING AND MOBILITY LLC 335 EISENHOWER LN S LOMBARD IL (630) DME 1/1/15 WALGREEN MEDICAL SUPPLY LLC TH AVE MOKENA IL (888) DME 1/1/15 WALGREENS HOME CARE INC TH ST CRESTWOOD IL (800) DME 9/1/15 WOUND CARE SOLUTIONS INC 2003 W FULTON ST CHICAGO IL (312) DME 2/1/17 ZOLL SERVICES LLC 121 GAMMA DR PITTSBURGH PA (800) A s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 5

6 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER HEARING AID SUPPLIER 8/1/16 COCHLEAR AMERICAS E PEAKVIEW AVE CENTENNIAL CO (800) A 4/1/17 HEARING AID SUPPLIER 1/1/15 TRU HEARING INC FRONTRUNNER BOULEVARD DRAPER UT (844) A 2/1/18 HEARING AID SUPPLIER 1/1/15 TRU HEARING INC 1901 N ROSELLE RD SCHAUMBURG IL (773) A s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 6

7 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER HOME HEALTH CARE 11/1/16 1ST FAMILY HOME HEALTHCARE INC 666 RUSSEL CT WOODSTOCK IL (815) HOME HEALTH CARE 9/1/15 A 2 Z HEALTHCARE SERVICE LLC TH CT ORLAND PARK IL (708) HOME HEALTH CARE 3/1/15 ABCOR HOME HEALTH INC 3201 N WILKE RD ARLINGTON HEIGHTS IL (847) HOME HEALTH CARE 4/1/16 ACE HEALTH CARE SERVICES LLC 4731 W MIDLOTHIAN TURNPIKE CRESTWOOD IL (708) HOME HEALTH CARE 4/1/16 ADDUS HEALTHCARE GOVERNORS HWY OLYMPIA FIELDS IL (708) HOME HEALTH CARE 9/1/16 ADVANCE HOME HEALTH INC 800 ROOSEVELT RD GLEN ELLYN IL (630) A 11/1/16 HOME HEALTH CARE 7/1/16 ADVANTAGE HOME HEALTH CARE INC 425 E US ROUTE 6 MORRIS IL (815) A 8/1/16 HOME HEALTH CARE 3/1/17 ADVENTIST HEALTH CARE AT HOME 5101 S WILLOW SPRINGS RD LA GRANGE IL (708) A 4/1/17 HOME HEALTH CARE 3/1/16 ALC HOME HEALTH CARE INC 477 E BUTTERFIELD RD LOMBARD IL (630) A 6/1/16 HOME HEALTH CARE 3/1/15 ALEXIAN BROTHERS HOME HEALTH AGE 1515 E LAKE ST HANOVER PARK IL (847) HOME HEALTH CARE 2/1/16 ALL FAMILY HEALTH CARE INC 6413 N KINZUA AVE CHICAGO IL (773) HOME HEALTH CARE 1/1/15 ALL QUALITY HOME HEALTH CARE LLC 395 E DUNDEE RD WHEELING IL (224) HOME HEALTH CARE 3/1/15 AMEDISYS HOME HEALTH 765 ELA RD LAKE ZURICH IL (847) HOME HEALTH CARE 3/1/15 AMEDISYS ILLINOIS OF TINLEY PARK CROSSING DR TINLEY PARK IL (708) HOME HEALTH CARE 2/1/16 AMERICHOICE HEALTH CARE INC 950 SKOKIE BLVD NORTHBROOK IL (847) HOME HEALTH CARE 5/1/15 ANGEL HEALTH CARE LLC 2625 BUTTERFIELD RD OAK BROOK IL (847) HOME HEALTH CARE 8/1/16 ANREX HEALTHCARE INC 6200 N HIAWATHA CHICAGO IL (773) A 9/1/16 HOME HEALTH CARE 8/1/16 ASPIRE HOME HEALTHCARE LLC 8930 WAUKEGAN RD MORTON GROVE IL (312) A 10/1/16 HOME HEALTH CARE 3/1/16 AT HOME HEALTH INC 3344 W PETERSON AVE CHICAGO IL (773) HOME HEALTH CARE 3/1/15 ATNT HOME HEALTH CARE INC WINTERSET DR ORLAND PARK IL (708) HOME HEALTH CARE 2/1/16 AUXILIUM HEALTHCARE SERVICES 129 FAIRFIELD WAY BLOOMINGDALE IL (224) HOME HEALTH CARE 9/1/15 AWESOME HOME HEALTH CARE S WESTERN AVE CHICAGO IL (773) HOME HEALTH CARE 8/1/17 BETTER CARE HOME HEALTH INC 2860 S RIVER RD DES PLAINES IL (847) A HOME HEALTH CARE 3/1/16 BETTER CHOICE HOME HEALTH INC 7250 N CICERO AVE LINCOLNWOOD IL (847) HOME HEALTH CARE 4/1/16 BG HOME HEALTH PROVIDERS LLC 133 W RAND ROAD ARLINGTON HEIGHTS IL (847) HOME HEALTH CARE 1/1/17 BOWES IN HOME CARE INC 906 IL ROUTE 22 FOX RIVER GROVE IL (847) HOME HEALTH CARE 1/1/17 CARE IN THE HOME HEALTH SERVS 1200 CENTRAL AVE WILMETTE IL (847) A 3/1/17 HOME HEALTH CARE 6/1/16 CARELINK HOME HEALTH LLC 33 W HIGGINS RD SOUTH BARRINGTON IL (847) A 6/1/16 HOME HEALTH CARE 7/1/16 CARESS HOME HEALTH CARE INC 3917 HOWARD STREET SKOKIE IL (847) A 9/1/16 HOME HEALTH CARE 1/1/17 CENTEGRA HOME HEALTH CARE 4201 W MEDICAL CENTER DR MCHENRY IL (815) HOME HEALTH CARE 5/1/16 CHICAGOLAND HOME HLTH PROV INC 2604 DEMPSTER ST PARK RIDGE IL (847) A 6/1/16 HOME HEALTH CARE 8/1/15 CHOICECARE HOME HEALTH INC 6400 W COLLEGE DR PALOS HTS IL (708) HOME HEALTH CARE 10/1/17 CLIENT HOME HEALTHCARE INC 9705 SOUTHWEST HIGHWAY OAK LAWN IL (708) A 12/1/17 HOME HEALTH CARE 3/1/15 COMPLETE HOME HEALTH SERVICES INC PRINCE DR SOUTH HOLLAND IL (708) HOME HEALTH CARE 9/1/17 CORNERSTONE HOME HEALTHCARE LLC 2800 S RIVER RD DES PLAINES IL (847) A 9/1/17 HOME HEALTH CARE 1/1/17 COVENANTCARE AT HOME 3755 E MAIN ST ST CHARLES IL (630) A 2/1/17 HOME HEALTH CARE 6/1/17 CRYSTAL HOME HEALTH CARE LLC 2720 S RIVER RD DES PLAINES IL (847) A HOME HEALTH CARE 6/1/15 DIRECT HOME HEALTHCARE INC 4001 W DEVON AVE CHICAGO IL (773) HOME HEALTH CARE 3/1/15 DIVINE INTERVENTION HLTHCARE INC 4747 LINCOLN MALL DR MATTESON IL (708) HOME HEALTH CARE 9/1/17 ELITE HOME HEALTHCARE SOLUTIONS 707 SKOKIE BLVD NORTHBROOK IL (847) A 9/1/17 HOME HEALTH CARE 11/1/16 ENTERA HEALTHCARE LTD 3349 MAIN ST SKOKIE IL (847) HOME HEALTH CARE 6/1/16 EVERGREEN HOME HEALTHCARE 6069 DEMPSTER ST MORTON GROVE IL (847) A 8/1/16 HOME HEALTH CARE 4/1/15 FAMILY HOME HEALTH SERVICES INC 2171 EXECUTIVE DR ADDISON IL (630) HOME HEALTH CARE 5/1/17 FIRST CARE HEALTHCARE INC 924 CLOCK TOWER DRIVE SPRINGFIELD IL (217) A HOME HEALTH CARE 8/1/15 FIRST HOME HEALTH CARE SERVICES KILBOURN MIDLOTHIAN IL (708) HOME HEALTH CARE 3/1/17 FORUM HEALTHCARE 900 SKOKIE BLVD NORTHBROOK IL (847) A 3/1/17 7

8 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER HOME HEALTH CARE 11/1/15 GENTLE PRO HOME HEALTH CARE INC 2060 E ALGONQUIN RD SCHAUMBURG IL (847) HOME HEALTH CARE 3/1/17 GIRLING HEALTHCARE INC 7222 W CERMAK RD NORTH RIVERSIDE IL (708) A HOME HEALTH CARE 1/1/17 GOODHOPE HEALTHCARE AND HOME 3631 MUNICIPAL DR MCHENRY IL (815) HOME HEALTH CARE 11/1/15 GOVVAS HEALTHCARE SERVICES INC 670 N 1ST BANK DR PALATINE IL (847) HOME HEALTH CARE 4/1/17 GUARDIAN ANGEL HOME CARE INC 1420 RENAISSANCE DR PARK RIDGE IL (847) A HOME HEALTH CARE 2/1/15 GUARDIAN HOME HEALTH CARE LLC 181 WAUKEGAN RD NORTHFIELD IL (847) HOME HEALTH CARE 5/1/15 HANDS OF WELLNESS INC 1062 SIBLEY BLVD CALUMET CITY IL (708) HOME HEALTH CARE 10/1/17 HEALTH RESOURCE SOLUTIONS 1806 S HIGHLAND AVE LOMBARD IL (312) A 11/1/17 HOME HEALTH CARE 12/1/16 HEALTHCARE PLUS CORPORATION 1272 N N W HWY PALATINE IL (847) A 1/1/17 HOME HEALTH CARE 6/1/15 HEALTHTRENDS LTD 200 E HOWARD AVE DES PLAINES IL (847) HOME HEALTH CARE 2/1/18 HOLISTIC HEALTH PARTNERS INC 7021 W 153RD STREET ORLAND PARK IL (708) A HOME HEALTH CARE 9/1/15 HOME CARE LIT CO OF MARY HOSP 2800 W 95TH ST EVERGREEN PARK IL (708) HOME HEALTH CARE 8/1/16 HOME HEALTH ADVANTAGE INC 6120 N MILWAUKEE AVE CHICAGO IL (773) A 10/1/16 HOME HEALTH CARE 7/1/16 HOME HEALTH CHOICE INC 8308 N LINCOLN AVE SKOKIE IL (847) A 8/1/16 HOME HEALTH CARE 5/1/17 HOME HEALTH OF ILLINOIS LLC 5061 N PULASKI RD CHICAGO IL (773) A HOME HEALTH CARE 11/1/16 HOME LIFE HEALTHCARE CORP 1020 W GOLF RD HOFFMAN ESTATES IL (847) HOME HEALTH CARE 2/1/17 INDEPENDENCE PLUS INC 720 ENTERPRISE DR OAK BROOK IL (630) A 2/1/17 HOME HEALTH CARE 3/1/17 INGALLS HOME CARE 1 INGALLS DR HARVEY IL (708) A HOME HEALTH CARE 2/1/16 INTEGRATED HOME HEALTHCARE SRVCS 900 TECHNOLOGY WAY LIBERTYVILLE IL (847) HOME HEALTH CARE 1/1/14 INTERIM HEALTHCARE S CICERO OAK LAWN IL (708) HOME HEALTH CARE 4/1/17 JN FAMILY HOME HEALTHCARE 8750 W BRYN MAWR AVE CHICAGO IL (773) A HOME HEALTH CARE 2/1/15 KINDRED AT HOME CHICAGO HOME HLTH 7101 N CICERO AVE LINCOLNWOOD IL (847) HOME HEALTH CARE 1/1/15 LEXINGTON HOME HEALTH CARE INC 1300 S MAIN STREET LOMBARD IL (630) HOME HEALTH CARE 9/1/16 LIFE CARE HOME HEALTH SERVICES 2255 MONARCH DR NAPERVILLE IL (630) A 11/1/16 HOME HEALTH CARE 6/1/15 LIFECARE HOME HLTH SERVICES INC 3400 DUNDEE RD NORTHBROOK IL (847) HOME HEALTH CARE 2/1/18 MEDI LINK HEALTH SERVICES LLC 1701 E WOODFIELD RD SCHAUMBURG IL (847) A HOME HEALTH CARE 10/1/15 MIRANDA HOME HEALTHCARE S KEDZIE AVE FLOSSMOOR IL (708) HOME HEALTH CARE 1/1/15 NORTHWEST COMM HOSP HOME CARE 3060 SALT CREEK LANE ARLINGTON HEIGHTS IL (847) HOME HEALTH CARE 1/1/17 NORTHWEST HOME HEALTH AND REHAB 9249 S RTE 31 LAKE IN THE HILLS IL (847) HOME HEALTH CARE 4/1/16 NORTHWESTERN ILLINOIS HOME HEALTH 151 TENNEY ST KEWANEE IL (309) HOME HEALTH CARE 1/1/14 NORTHWESTERN MED HOME HLTH HOSPIC 690 E NORTH AVE CAROL STREAM IL (630) HOME HEALTH CARE 1/1/17 NOVA HOME HEALTHCARE INC 6900 MAIN ST DOWNERS GROVE IL (630) A 2/1/17 HOME HEALTH CARE 1/1/15 O AND P HOME HEALTH CARE INC 4950 MAIN ST SKOKIE IL (847) HOME HEALTH CARE 4/1/17 OPTION CARE ENTERPRISES INC 1226 MICHAEL DR WOOD DALE IL (800) A HOME HEALTH CARE 4/1/17 OPTION CARE ENTERPRISES INC 2050 S FINLEY RD LOMBARD IL (630) A HOME HEALTH CARE 10/1/15 PALOS COMMUNITY HOSP HOME HEALTH E 127TH ST LEMONT IL (630) HOME HEALTH CARE 1/1/15 PEAK HOME HLTHC DBA NEWSOME HOME 920 ESSINGTON RD JOLIET IL (815) HOME HEALTH CARE 1/1/17 PF DEVELOPMENT 5 LLC 4430 MANCHESTER DR ROCKFORD IL (815) A 2/1/17 HOME HEALTH CARE 1/1/17 PF DEVELOPMENT 5 LLC 2401 W US HWY 20 PINGREE GROVE IL (847) A 2/1/17 HOME HEALTH CARE 9/1/15 PHOENIX HOME CARE LLC 200 S FRONTAGE RD BURR RIDGE IL (630) HOME HEALTH CARE 9/1/15 PREMIER POINT HOME HEALTH NFP 4701 N SHERIDAN RD CHICAGO IL (773) HOME HEALTH CARE 1/1/14 PRIVATE HOME CARE UNLIMITED 5517 N CUMBERLAND CHICAGO IL (773) HOME HEALTH CARE 10/1/17 PROVIDENCE AT HOME HEALTHCARE NORTH CREEK DR TINLEY PARK IL (800) A 9/1/17 HOME HEALTH CARE 6/1/16 PRUDENT CHOICE HOME HLTH CARE COR 1699 E WOODFIELD RD SCHAUMBURG IL (847) A 8/1/16 HOME HEALTH CARE 11/1/16 RELIANCE HOME HEALTH CARE INC 3701 ALGONQUIN RD ROLLING MEADOWS IL (847) HOME HEALTH CARE 8/1/16 RESILIENCE HOME HEALTH CORP 31 KENDALL POINT DR OSWEGO IL (630) A 9/1/16 HOME HEALTH CARE 1/1/17 RMC HOME HEALTH CARE 611 DIVISION ST PEOTONE IL (815) A 7/1/17 HOME HEALTH CARE 9/1/17 SENIOR CARE AT HOME INC 7021 W 153RD ST ORLAND PARK IL (708) A 9/1/17 8

9 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER HOME HEALTH CARE 7/1/16 SERENITY HOME HEALTHCARE 6677 N LINCOLN AVE LINCOLNWOOD IL (773) A 8/1/16 HOME HEALTH CARE 6/1/15 SHAY HEALTHCARE SERVICES 5730 W 159TH ST OAK FOREST IL (708) HOME HEALTH CARE 1/1/15 SILVER CROSS HOME HEALTH 1900 SILVER CROSS BLVD NEW LENOX IL (815) HOME HEALTH CARE 3/1/16 SOLARIS HOME HEALTHCARE INC 3330 DUNDEE RD NORTHBROOK IL (847) HOME HEALTH CARE 5/1/15 STAR HOME HEALTH SERVICES INC /2 SOUTH KEDZIE CHICAGO IL (773) HOME HEALTH CARE 5/1/15 TOTAL HOME HEALTHCARE 4001 WEST DEVON CHICAGO IL (773) HOME HEALTH CARE 1/1/15 URBAN HEALTH LLC 224 S MILWAUKEE AVE WHEELING IL (312) HOME HEALTH CARE 1/1/15 VANGUARD HEALTH AND WELLNESS 1585 ELLINWOOD AVE DES PLAINES IL (855) HOME HEALTH CARE 10/1/16 VITAL HOME HEALTH CARE 8051 W 186TH ST TINLEY PARK IL (708) A 11/1/16 HOME HEALTH CARE 7/1/15 WHOLE LIFE HOME HEALTH 7501 N MILWAUKEE AVE NILES IL (847) HOME HEALTH CARE 3/1/16 WOUND AND REHAB HM HLTH CARE INC 700 BUSSE HIGHWAY PARK RIDGE IL (847) s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 9

10 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER HOME INFUSION 8/1/16 BIOSCRIP INFUSION SERVICES 321 W LAKE ST ELMHURST IL (630) A 7/1/17 HOME INFUSION 1/1/14 CENTRAL DUPAGE SPECIAL HLTH ASSOC 690 E NORTH AVE CAROL STREAM IL (630) HOME INFUSION 6/1/16 IV SOLUTIONS LLC 420 LAKE COOK RD DEERFIELD IL (847) A 6/1/16 HOME INFUSION 1/1/14 METRO INFECTIOUS DISEASE CONSULTS 901 MCCLINTOCK DR BURR RIDGE IL (630) HOME INFUSION 1/1/15 OPTION CARE ENTERPRISE 1226 MICHAEL DR WOOD DALE IL (800) A HOME INFUSION 1/1/15 OPTION CARE ENTERPRISES 2050 S FINLEY RD LOMBARD IL (630) HOME INFUSION 8/1/16 OPTION HEALTH LTD 321 W LAKE ST ELMHURST IL (630) A 9/1/16 HOME INFUSION 6/1/15 OPTION HEALTH LTD 985 AVE OF THE CITIES SILVIS IL (309) HOME INFUSION 1/1/18 PHARMASCRIPT INC 5437 N BROADWAY ST CHICAGO IL (773) A HOME INFUSION 1/1/17 RIVERSIDE HOME INFUSION 350 N WALL ST KANKAKEE IL (815) A HOME INFUSION 3/21/17 RUSH UNIVERSITY MED CNTR 610 S MAPLE AVE OAK PARK IL (708) A HOME INFUSION 8/1/15 RUSH UNIVERSITY MED CNTR 1725 W HARRISON ST CHICAGO IL (312) HOME INFUSION 1/1/16 RX CONSULT INC DBA HEALTH OPTIONS 110 S MARKET ST SPARTA IL (618) s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 10

11 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER HOSPICE 4/1/16 ACCORD HOSPICE INC 1247 LYNN TERRACE HIGHLAND PARK IL (847) HOSPICE 3/1/15 ALEXIAN BROTHERS HOSPICE 1515 E LAKE ST HANOVER PARK IL (630) HOSPICE 1/1/15 CNS HOME HEALTH 690 E NORTH AVE CAROL STREAM IL (630) HOSPICE 2/1/17 COMFORT HOSPICE AND PALLIATIVE 8750 W BRYN MAWR AVE CHICAGO IL (847) A 3/1/17 HOSPICE 9/1/14 COVENANT HOME SERVICES 3755 E MAIN ST ST CHARLES IL (630) HOSPICE 4/1/15 FAMILY CENTERED HOSPICE 2171 EXECUTIVE DR ADDISON IL (630) HOSPICE 4/1/17 HARBOR LIGHT HOSPICE 800 ROOSEVELT RD GLEN ELLYN IL (800) A 4/1/17 HOSPICE 4/1/17 HOPE PALLIATIVE AND HOSPICE CARE 1274 W NORTHWEST HWY PALATINE IL (847) A 4/1/17 HOSPICE 7/1/15 HOSPICE ADVANTAGE 16W485 S FRONTAGE BURR RIDGE IL (708) HOSPICE 3/1/16 HOSPICE OF GREATER CHICAGO LLC 1727 S INDIANA AVE CHICAGO IL (630) HOSPICE 3/1/17 INGALLS HOME HOSPICE 1 INGALLS DR HARVEY IL (708) A HOSPICE 2/1/16 INTEGRATED PALLIATIVE HOSPICE LLC 900 TECHNOLOGY WAY LIBERTYVILLE IL (847) HOSPICE 1/1/15 LEXINGTON HOSPICE SERVICES LLC 1300 S MAIN STREET LOMBARD IL (630) HOSPICE 9/1/15 LITTLE COMPANY OF MARY HOSPICE 9800 SOUTHWEST HWY OAK LAWN IL (708) HOSPICE 10/1/15 PALOS COMMUNITY HOSPITAL HOSPICE E 127TH ST LEMONT IL (630) HOSPICE 1/1/14 RAINBOW HOSPICE AND PALLIATIVE 1550 BISHOP CT MOUNT PROSPECT IL (847) HOSPICE 8/1/15 RESIDENTIAL HOSPICE ILLINOIS 1431 OPUS PLACE DOWNERS GROVE IL (855) HOSPICE 5/1/17 SOLACE HOSPICE & PALLIATIVE CARE 650 E DEVON AVE ITASCA IL (847) A HOSPICE 3/1/17 ST THOMAS HOSPICE 119 E OGDEN AVE HINSDALE IL (630) A HOSPICE 3/1/17 TRANSITIONS HOSPICE LLC RAYMOND CT HUNTLEY IL (224) A 4/1/17 HOSPICE 1/1/17 1/1/17 TRANSITIONS HOSPICE LLC RAYMOND COURT HUNTLEY IL (815) C 2/1/17 HOSPICE 1/1/14 VITAS INNOVATVE HOSPICE CARE CHGO 1340 S DAMEN AVE CHICAGO IL (312) s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 11

12 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER INPATIENT - METRO 1/1/14 ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL (630) INPATIENT - METRO 1/1/14 ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL (630) INPATIENT - METRO 1/1/14 ADVENTIST GLEN OAKS HOSPITAL 701 WINTHROP AVE GLENDALE HEIGHTS IL (630) INPATIENT - METRO 1/1/14 ADVENTIST HINSDALE HOSPITAL 120 N OAK ST HINSDALE IL (630) INPATIENT - METRO 1/1/14 ADVENTIST LAGRANGE MEMORIAL HOSP 5101 S WILLOW SPRINGS RD LA GRANGE IL (708) INPATIENT - METRO 1/1/16 ADVOCATE BROMENN MEDICAL CTR 1304 FRANKLIN AVE NORMAL IL (309) INPATIENT - METRO 1/1/14 ADVOCATE CHRIST HOSP MED CNTR 4440 W 95TH ST OAK LAWN IL (708) INPATIENT - METRO 1/1/14 ADVOCATE CONDELL MEDICAL CENTER 801 S MILWAUKEE AVE LIBERTYVILLE IL (847) INPATIENT - METRO 1/1/14 ADVOCATE GOOD SAMARITAN HOSPITAL 3815 HIGHLAND AVE DOWNERS GROVE IL (630) INPATIENT - METRO 1/1/14 ADVOCATE GOOD SHEPHERD HOSPITAL 450 W HIGHWAY 22 BARRINGTON IL (847) INPATIENT - METRO 1/1/14 ADVOCATE ILLINOIS MASONIC MED CNT 836 W WELLINGTON AVE CHICAGO IL (773) INPATIENT - METRO 1/1/14 ADVOCATE LUTHERAN GENERAL HOSP 1775 DEMPSTER ST PARK RIDGE IL (847) INPATIENT - METRO 1/1/14 ADVOCATE SHERMAN HOSPITAL 1425 N RANDALL RD ELGIN IL (847) INPATIENT - METRO 1/1/14 ADVOCATE SOUTH SUBURBAN HOSPITAL S KEDZIE AVE HAZEL CREST IL (708) INPATIENT - METRO 1/1/14 ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO IL (773) INPATIENT - METRO 1/1/14 ALEXIAN BROTHERS BEHAVIORAL HLTH 1650 MOON LAKE BLVD HOFFMAN ESTATES IL (847) INPATIENT - METRO 1/1/14 ALEXIAN BROTHERS MEDICAL CENTER 800 BIESTERFIELD RD ELK GROVE VILLAGE IL (847) INPATIENT - METRO 11/1/17 AURORA CHICAGO LAKESHORE HOSP 4840 N MARINE DR CHICAGO IL (773) A INPATIENT - METRO 1/1/17 CENTEGRA HOSPITAL MCHENRY 4201 W MEDICAL CENTER DR MCHENRY IL (815) A 10/1/16 INPATIENT - METRO 1/1/17 CENTEGRA HOSPITAL WOODSTOCK 3701 DOTY RD WOODSTOCK IL (815) A 10/1/16 INPATIENT - METRO 1/1/14 CENTRAL DUPAGE HOSPITAL 25 N WINFIELD RD WINFIELD IL (630) INPATIENT - METRO 11/1/15 CHICAGO BEHAVIORAL HOSPITAL 555 WILSON RD DES PLAINES IL (847) INPATIENT - METRO 1/1/15 COMMUNITY FIRST MEDICAL CENTER 5645 W ADDISON ST CHICAGO IL (773) INPATIENT - METRO 1/1/14 COPLEY MEMORIAL HOSPITAL 2000 OGDEN AVE AURORA IL (630) INPATIENT - METRO 1/1/14 DELNOR COMMUNITY HOSPITAL 300 RANDALL RD GENEVA IL (630) INPATIENT - METRO 1/1/14 EDWARD HOSPITAL 801 S WASHINGTON ST NAPERVILLE IL (630) INPATIENT - METRO 1/1/14 ELMHURST MEM HOSPITAL MAIN CAMPUS 155 E BRUSH HILL RD ELMHURST IL (331) INPATIENT - METRO 1/1/17 GOTTLIEB MEMORIAL HOSPITAL 701 W NORTH AVE MELROSE PARK IL (708) A 10/1/16 INPATIENT - METRO 1/1/18 HEARTLAND REGIONAL MEDICAL CTR 3333 W DE YOUNG MARION IL (618) A INPATIENT - METRO 1/1/14 HOLY CROSS HOSPITAL 2701 W 68TH ST CHICAGO IL (773) INPATIENT - METRO 1/1/15 INGALLS MEMORIAL HOSPITAL 1 INGALLS DR HARVEY IL (708) INPATIENT - METRO 11/1/15 KINDRED CHGO CENTRAL HOSPITAL 4058 W MELROSE ST CHICAGO IL (773) INPATIENT - METRO 11/1/15 KINDRED CHGO CENTRAL HOSPITAL 4058 W MELROSE ST CHICAGO IL (773) INPATIENT - METRO 11/1/15 KINDRED HOSP NORTHLAKE 365 E NORTH AVE NORTHLAKE IL (708) INPATIENT - METRO 11/1/15 KINDRED HOSP NORTHLAKE 365 E NORTH AVE NORTHLAKE IL (708) INPATIENT - METRO 11/1/15 KINDRED HOSPITAL CHICAGO NORTH 2544 W MONTROSE CHICAGO IL (773) A 10/1/16 INPATIENT - METRO 11/1/15 KINDRED HOSPITAL SYCAMORE 225 EDWARD ST SYCAMORE IL (815) INPATIENT - METRO 1/1/14 KISHWAUKEE COMMUNITY HOSPITAL 1 KISH HOSPITAL DR DEKALB IL (815) INPATIENT - METRO 1/1/14 KISHWAUKEE COMMUNITY HOSPITAL 1 KISH HOSPITAL DR DEKALB IL (815) INPATIENT - METRO 1/1/14 LINDEN OAKS HOSPITAL 852 WEST ST NAPERVILLE IL (630) INPATIENT - METRO 1/1/14 LITTLE COMPANY OF MARY HOSP 2800 W 95TH ST EVERGREEN PARK IL (708) INPATIENT - METRO 1/1/17 LOYOLA UNIVERSITY MEDICAL CENTER 2160 S FIRST AVE MAYWOOD IL (708) A 10/1/16 INPATIENT - METRO 1/1/14 MACNEAL HOSPITAL 3249 S OAK PARK AVE BERWYN IL (708) INPATIENT - METRO 1/1/14 MARIANJOY REHABILITATION HOSPITAL 26 W 171 ROOSEVELT RD WHEATON IL (630) INPATIENT - METRO 1/1/17 MERCY HOSPITAL AND MEDICAL CENTER 2525 S MICHIGAN AVE CHICAGO IL (312) A 10/1/16 INPATIENT - METRO 12/1/16 METROSOUTH MEDICAL CENTER S GREGORY ST BLUE ISLAND IL (708)

13 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER INPATIENT - METRO 1/1/14 MOUNT SINAI HOSPITAL 1500 S. CALIFORNIA CHICAGO IL (773) INPATIENT - METRO 1/1/14 NORTHSHORE EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON IL (847) INPATIENT - METRO 1/1/14 NORTHSHORE GLENBROOK HOSPITAL 2100 PFINGSTEN RD GLENVIEW IL (847) INPATIENT - METRO 1/1/14 NORTHSHORE HIGHLAND PARK HOSPITAL 777 PARK AVE WEST HIGHLAND PARK IL (847) INPATIENT - METRO 1/1/14 NORTHSHORE SKOKIE HOSPITAL 9600 GROSS POINT RD SKOKIE IL (847) INPATIENT - METRO 1/1/14 NORTHWEST COMMUNITY HOSPITAL 800 W CENTRAL RD ARLINGTON HEIGHTS IL (847) INPATIENT - METRO 1/1/17 NORTHWESTERN LAKE FOREST HOSPITAL 660 N WESTMORELAND RD LAKE FOREST IL (847) A 7/1/17 INPATIENT - METRO 1/1/17 NORTHWESTERN MEMORIAL HOSPITAL 251 E HURON CHICAGO IL (312) A 7/1/17 INPATIENT - METRO 1/1/14 PALOS COMMUNITY HOSPITAL S 80TH AVE PALOS HEIGHTS IL (708) INPATIENT - METRO 1/1/14 PRESENCE COVENANT MEDICAL CENTER 1400 W PARK ST URBANA IL (217) INPATIENT - METRO 1/1/14 PRESENCE HOLY FAMILY MEDICAL CTR 100 N RIVER RD DES PLAINES IL (847) INPATIENT - METRO 1/1/14 PRESENCE MERCY MEDICAL CENTER 1325 N HIGHLAND AVE AURORA IL (630) INPATIENT - METRO 1/1/14 PRESENCE RESURRECTION MED CTR 7435 W TALCOTT AVE CHICAGO IL (773) INPATIENT - METRO 1/1/14 PRESENCE ST FRANCIS HOSPITAL 355 RIDGE AVE EVANSTON IL (847) INPATIENT - METRO 1/1/14 PRESENCE ST JOSEPH HOSP CHICAGO 2900 N LAKE SHORE DR CHICAGO IL (773) INPATIENT - METRO 1/1/14 PRESENCE ST JOSEPH HOSP CHICAGO 2900 N LAKE SHORE DR CHICAGO IL (773) INPATIENT - METRO 1/1/14 PRESENCE ST JOSEPH HOSP ELGIN 77 N AIRLITE ST ELGIN IL (847) INPATIENT - METRO 1/1/14 PRESENCE ST JOSEPH MEDICAL CTR 333 N MADISON ST JOLIET IL (815) INPATIENT - METRO 1/1/14 PRESENCE ST MARY ELIZABETH MDCT 2233 W DIVISION ST CHICAGO IL (312) INPATIENT - METRO 1/1/14 PRESENCE ST MARYS HOSPITAL 500 W COURT ST KANKAKEE IL (815) INPATIENT - METRO 1/1/14 PRESENCE UNITED SAMARITANS MED CT 812 N LOGAN AVE DANVILLE IL (217) INPATIENT - METRO 1/1/17 RIVERSIDE MEDICAL CENTER 350 N WALL ST KANKAKEE IL (815) A 11/1/16 INPATIENT - METRO 1/1/14 RML SPECIALTY HOSPITAL 5601 S COUNTY LINE RD HINSDALE IL (630) INPATIENT - METRO 1/1/14 RML SPECIALTY HOSPITAL 5601 S COUNTY LINE RD HINSDALE IL (630) INPATIENT - METRO 1/1/17 RUSH OAK PARK HOSPITAL 520 S MAPLE AVE OAK PARK IL (708) A 11/1/16 INPATIENT - METRO 1/1/17 RUSH UNIVERSITY MEDICAL CENTER 1653 W CONGRESS PKWY CHICAGO IL (312) A 11/1/16 INPATIENT - METRO 7/1/15 SAINT ANTHONY HOSPITAL 2875 W 19TH ST CHICAGO IL (773) INPATIENT - METRO 7/1/15 SAINT ANTHONY HOSPITAL 2875 W 19TH ST CHICAGO IL (773) INPATIENT - METRO 1/1/14 SCHWAB REHABILITATION HOSPITAL 1401 S CALIFORNIA AVE CHICAGO IL (773) INPATIENT - METRO 1/1/14 SILVER CROSS HOSPITAL 1900 SILVER CROSS BLVD NEW LENOX IL (815) INPATIENT - METRO 1/1/14 ST ALEXIUS MEDICAL CENTER 1555 BARRINGTON RD HOFFMAN ESTATES IL (847) INPATIENT - METRO 1/1/14 ST BERNARD HOSPITAL 326 W 64TH ST CHICAGO IL (773) INPATIENT - METRO 1/1/14 ST JAMES HOSPITAL AND HLTH CNTRS 1423 CHICAGO RD CHICAGO HEIGHTS IL (708) INPATIENT - METRO 1/1/14 SWEDISH COVENANT HOSPITAL 5145 N CALIFORNIA AVE CHICAGO IL (773) INPATIENT - METRO 3/1/16 THOREK MEMORIAL HOSPITAL 850 W IRVING PARK RD CHICAGO IL (773) INPATIENT - METRO 1/1/18 UNION COUNTY HOSPITAL 517 N MAIN ST ANNA IL (618) A 2/1/18 INPATIENT - METRO 1/1/14 UNIVERSITY OF CHICAGO MEDICAL CEN 5841 S MARYLAND AVE CHICAGO IL (773) INPATIENT - METRO 1/1/14 VALLEY WEST COMMUNITY HOSPITAL 11 E PLEASANT AVE SANDWICH IL (815) INPATIENT - METRO 1/1/14 VALLEY WEST COMMUNITY HOSPITAL 11 E PLEASANT AVE SANDWICH IL (815) INPATIENT - METRO 11/1/17 VAN MATRE HEALTH SOUTH REHAB CTR 950 S MULFORD RD ROCKFORD IL (815) A 11/1/17 INPATIENT - METRO 7/1/17 VISTA MEDICAL CENTER EAST 1324 N SHERIDAN RD WAUKEGAN IL (847) A INPATIENT - METRO 1/1/14 WEISS MEMORIAL HOSPITAL 4646 N MARINE DR CHICAGO IL (773) INPATIENT - METRO 1/1/14 WEISS MEMORIAL HOSPITAL 4646 N MARINE DR CHICAGO IL (773) INPATIENT - METRO 1/1/14 WEST SUBURBAN MEDICAL CENTER 3 ERIE COURT OAK PARK IL (708) INPATIENT - METRO 1/1/14 WESTLAKE HOSPITAL INC 1225 W LAKE ST MELROSE PARK IL (708)

14 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 14

15 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER MENTAL HEALTH 11/1/15 CHICAGO BEHAVIORAL HOSPITAL 555 WILSON RD DES PLAINES IL (847) MENTAL HEALTH 1/1/14 LINDEN OAKS HOSPITAL 852 WEST ST NAPERVILLE IL (630) s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 15

16 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER ORTHOTIC & PROSTHETIC 2/1/16 BALLERT ORTHOPEDIC OF CHICAGO 1250 N MILL ST NAPERVILLE IL (630) ORTHOTIC & PROSTHETIC 2/1/16 BALLERT ORTHOPEDIC OF CHICAGO FRONT ST WOOD DALE IL (630) ORTHOTIC & PROSTHETIC 2/1/16 BALLERT ORTHOPEDIC OF CHICAGO 233 E ERIE ST CHICAGO IL (312) ORTHOTIC & PROSTHETIC 3/1/15 BALLERT ORTHOPEDIC OF CHICAGO 2434 W PETERSON AVE CHICAGO IL (773) ORTHOTIC & PROSTHETIC 1/1/17 BENCH MARK ATLANTIC HLTHCARE INC 5407 BULL VALLEY RD MCHENRY IL (815) ORTHOTIC & PROSTHETIC 1/1/17 GULBRANDSON ORTHO & PROS LTD 2615 THREE OAKS RD CARY IL (847) ORTHOTIC & PROSTHETIC 3/1/16 HANGER PROSTHETICS & ORTHOTIC INC 1910 S MT ZION RD DECATUR IL (217) ORTHOTIC & PROSTHETIC 3/1/16 HANGER PROSTHETICS AND ORTHOTICS 3691 COUGAR DR PERU IL (815) ORTHOTIC & PROSTHETIC 8/1/15 HANGER PROSTHETICS AND ORTHOTICS 311 W ROMEO B GARRETT AVE PEORIA IL (309) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHO EAST 100 TOWER DR BURR RIDGE IL (630) ORTHOTIC & PROSTHETIC 8/1/16 HANGER PROSTHETICS ORTHOTICS 4255 WESTBROOK DR AURORA IL (630) A 9/1/16 ORTHOTIC & PROSTHETIC 1/1/17 HANGER PROSTHETICS ORTHOTICS 620 S ROUTE 31 MCHENRY IL (815) ORTHOTIC & PROSTHETIC 3/1/16 HANGER PROSTHETICS ORTHOTICS 719 N WILLIAM KUMPF BLVD PEORIA IL (309) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS 694 ESSINGTON RD JOLIET IL (815) ORTHOTIC & PROSTHETIC 1/1/14 3/1/15 HANGER PROSTHETICS ORTHOTICS 75 MARKET ST ELGIN IL (847) C 2/1/17 ORTHOTIC & PROSTHETIC 3/1/16 3/1/16 HANGER PROSTHETICS ORTHOTICS 7 BRONZE POINTE SOUTH BELLEVILLE IL (618) C 2/1/17 ORTHOTIC & PROSTHETIC 1/1/14 1/1/14 HANGER PROSTHETICS ORTHOTICS 1 S 224 SUMMIT AVE OAKBROOK TERRACE IL (630) C 2/1/17 ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS 4525 W LINCOLN HWY MATTESON IL (708) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS 4801 W PETERSON AVE CHICAGO IL (773) ORTHOTIC & PROSTHETIC 1/1/14 11/23/16 HANGER PROSTHETICS ORTHOTICS 1123 EMERSON ST EVANSTON IL (847) C 2/1/17 ORTHOTIC & PROSTHETIC 1/1/14 1/2/14 HANGER PROSTHETICS ORTHOTICS W 160TH ST ORLAND PARK IL (708) C 2/1/17 ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS S CICERO AVE OAK LAWN IL (708) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS W CERMAK RD WESTCHESTER IL (708) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS S KEDZIE AVE HAZEL CREST IL (708) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS 35 TOWER CT GURNEE IL (847) ORTHOTIC & PROSTHETIC 1/1/14 HANGER PROSTHETICS ORTHOTICS 4255 WESTBROOK DR AURORA IL (630) ORTHOTIC & PROSTHETIC 7/1/15 NATURALLY YOURS INC 7219 KINGERY HWY WILLOWBROOK IL (630) ORTHOTIC & PROSTHETIC 10/1/16 RINNELLA ORTHOTICS INC 1890 SILVER CROSS BLVD NEW LENOZ IL (815) A ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 1725 W HARRISON ST CHICAGO IL (312) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 1551 BOND ST NAPERVILLE IL (630) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 1S376 SUMMIT AVE OAK BROOK TERRACE IL (630) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 2835 N SHEFFIELD CHICAGO IL (773) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 1740 W TAYLOR ST CHICAGO IL (312) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 10 N FAIRLANE DR JOLIET IL (847) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 401 HARRISON ST OAK PARK IL (708) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 5202 OLD ORCHARD RD SKOKIE IL (847) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 617 E GOLF RD ARLINGTON HEIGHTS IL (847) ORTHOTIC & PROSTHETIC 1/1/14 SCHECK AND SIRESS PROSTHETICS INC 8641 W 95TH ST HICKORY HILLS IL (708) ORTHOTIC & PROSTHETIC 12/1/17 BIONIC PROSTHETICS AND ORTHOTICS HARLEM AVENUE TINLEY PARK IL (708) A 2/1/18 ORTHOTIC & PROSTHETIC 12/1/17 BIONIC PROSTHETICS AND ORTHOTICS KEDZIE AVENUE HAZEL CREST IL (708) A 2/1/18 ORTHOTIC & PROSTHETIC 12/1/17 BIONIC PROSTHETICS AND ORTHOTICS 4315 N LINCOLN AVENUE CHICAGO IL (773) A 2/1/18 ORTHOTIC & PROSTHETIC 8/1/17 SECOND ACT LLC 2924 N LINCOLN AVE CHICAGO IL (773) A 16

17 Eff Organization Name Office Address 1 City State Zip PHONE NUMBER s: A: New C: N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation AD: Address CP: prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class 17

18 Medicare Advantage PPO Appendix D Provider Type Eff Organization Name Office Address 1 City State Zip PHONE NUMBER OUTPATIENT SURGERY 1/1/14 ADVENTIST GLEN OAKS HOSPITAL 701 WINTHROP AVE GLENDALE HEIGHTS IL (630) OUTPATIENT SURGERY 1/1/14 ADVENTIST HINSDALE HOSPITAL 120 N OAK ST HINSDALE IL (630) OUTPATIENT SURGERY 1/1/14 ADVENTIST LAGRANGE MEMORIAL HOSP 5101 S WILLOW SPRINGS RD LA GRANGE IL (708) OUTPATIENT SURGERY 1/1/16 ADVOCATE BROMENN MEDICAL CTR 1304 FRANKLIN AVE NORMAL IL (309) OUTPATIENT SURGERY 1/1/14 ADVOCATE CHRIST HOSP MED CNTR 4440 W 95TH ST OAK LAWN IL (708) OUTPATIENT SURGERY 1/1/14 ADVOCATE CONDELL MEDICAL CENTER 801 S MILWAUKEE AVE LIBERTYVILLE IL (847) OUTPATIENT SURGERY 1/1/14 ADVOCATE GOOD SAMARITAN HOSPITAL 3815 HIGHLAND AVE DOWNERS GROVE IL (630) OUTPATIENT SURGERY 1/1/14 ADVOCATE GOOD SHEPHERD HOSPITAL 450 W HIGHWAY 22 BARRINGTON IL (847) OUTPATIENT SURGERY 1/1/14 ADVOCATE ILLINOIS MASONIC MED CNT 836 W WELLINGTON AVE CHICAGO IL (773) OUTPATIENT SURGERY 1/1/14 ADVOCATE LUTHERAN GENERAL HOSP 1775 DEMPSTER ST PARK RIDGE IL (847) OUTPATIENT SURGERY 1/1/14 ADVOCATE SHERMAN HOSPITAL 1425 N RANDALL RD ELGIN IL (847) OUTPATIENT SURGERY 1/1/14 ADVOCATE SOUTH SUBURBAN HOSPITAL S KEDZIE AVE HAZEL CREST IL (708) OUTPATIENT SURGERY 1/1/14 ADVOCATE TRINITY HOSPITAL 2320 E 93RD ST CHICAGO IL (773) OUTPATIENT SURGERY 1/1/14 ALEXIAN BROTHERS BEHAVIORAL HLTH 1650 MOON LAKE BLVD HOFFMAN ESTATES IL (847) OUTPATIENT SURGERY 1/1/14 ALEXIAN BROTHERS MEDICAL CENTER 800 BIESTERFIELD RD ELK GROVE VILLAGE IL (847) OUTPATIENT SURGERY 11/1/17 AURORA CHICAGO LAKESHORE HOSP 4840 N MARINE DR CHICAGO IL (773) A OUTPATIENT SURGERY 1/1/17 CENTEGRA HOSPITAL MCHENRY 4201 W MEDICAL CENTER DR MCHENRY IL (815) A 10/1/16 OUTPATIENT SURGERY 1/1/17 CENTEGRA HOSPITAL WOODSTOCK 3701 DOTY RD WOODSTOCK IL (815) A 10/1/16 OUTPATIENT SURGERY 1/1/14 CENTRAL DUPAGE HOSPITAL 25 N WINFIELD RD WINFIELD IL (630) OUTPATIENT SURGERY 11/1/15 CHICAGO BEHAVIORAL HOSPITAL 555 WILSON RD DES PLAINES IL (847) OUTPATIENT SURGERY 1/1/15 COMMUNITY FIRST MEDICAL CENTER 5645 W ADDISON ST CHICAGO IL (773) OUTPATIENT SURGERY 1/1/14 COPLEY MEMORIAL HOSPITAL 2000 OGDEN AVE AURORA IL (630) OUTPATIENT SURGERY 1/1/14 DELNOR COMMUNITY HOSPITAL 300 RANDALL RD GENEVA IL (630) OUTPATIENT SURGERY 1/1/14 EDWARD HOSPITAL 801 S WASHINGTON ST NAPERVILLE IL (630) OUTPATIENT SURGERY 1/1/14 ELMHURST MEM HOSPITAL MAIN CAMPUS 155 E BRUSH HILL RD ELMHURST IL (331) OUTPATIENT SURGERY 1/1/17 GOTTLIEB MEMORIAL HOSPITAL 701 W NORTH AVE MELROSE PARK IL (708) A 10/1/16 OUTPATIENT SURGERY 1/1/18 HEARTLAND REGIONAL MEDICAL CTR 3333 W DE YOUNG MARION IL (618) A OUTPATIENT SURGERY 1/1/14 HOLY CROSS HOSPITAL 2701 W 68TH ST CHICAGO IL (773) OUTPATIENT SURGERY 1/1/15 INGALLS MEMORIAL HOSPITAL 1 INGALLS DR HARVEY IL (708) OUTPATIENT SURGERY 11/1/15 KINDRED HOSPITAL CHICAGO NORTH 2544 W MONTROSE CHICAGO IL (773) A 10/1/16 OUTPATIENT SURGERY 11/1/15 KINDRED HOSPITAL SYCAMORE 225 EDWARD ST SYCAMORE IL (815) OUTPATIENT SURGERY 1/1/14 LINDEN OAKS HOSPITAL 852 WEST ST NAPERVILLE IL (630) OUTPATIENT SURGERY 1/1/14 LITTLE COMPANY OF MARY HOSP 2800 W 95TH ST EVERGREEN PARK IL (708) OUTPATIENT SURGERY 1/1/17 LOYOLA UNIVERSITY MEDICAL CENTER 2160 S FIRST AVE MAYWOOD IL (708) A 10/1/16 OUTPATIENT SURGERY 1/1/14 MACNEAL HOSPITAL 3249 S OAK PARK AVE BERWYN IL (708) OUTPATIENT SURGERY 1/1/14 MARIANJOY REHABILITATION HOSPITAL 26 W 171 ROOSEVELT RD WHEATON IL (630) OUTPATIENT SURGERY 12/1/16 METROSOUTH MEDICAL CENTER S GREGORY ST BLUE ISLAND IL (708) OUTPATIENT SURGERY 1/1/14 MOUNT SINAI HOSPITAL 1500 S. CALIFORNIA CHICAGO IL (773) OUTPATIENT SURGERY 1/1/14 NORTHSHORE EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON IL (847) OUTPATIENT SURGERY 1/1/14 NORTHSHORE GLENBROOK HOSPITAL 2100 PFINGSTEN RD GLENVIEW IL (847) OUTPATIENT SURGERY 1/1/14 NORTHSHORE HIGHLAND PARK HOSPITAL 777 PARK AVE WEST HIGHLAND PARK IL (847) OUTPATIENT SURGERY 1/1/14 NORTHSHORE SKOKIE HOSPITAL 9600 GROSS POINT RD SKOKIE IL (847) OUTPATIENT SURGERY 1/1/14 NORTHWEST COMMUNITY HOSPITAL 800 W CENTRAL RD ARLINGTON HEIGHTS IL (847) OUTPATIENT SURGERY 1/1/17 NORTHWESTERN LAKE FOREST HOSPITAL 660 N WESTMORELAND RD LAKE FOREST IL (847) A 7/1/17 OUTPATIENT SURGERY 1/1/17 NORTHWESTERN MEMORIAL HOSPITAL 251 E HURON CHICAGO IL (312) A 7/1/17 OUTPATIENT SURGERY 1/1/14 PALOS COMMUNITY HOSPITAL S 80TH AVE PALOS HEIGHTS IL (708)