Formulary Names by State, County and Plan

Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Formulary Names by State, County and Plan 2015 PDP PDP Plan Name Formulary Name Aetna Medicare Rx Saver (PDP) Save Formulary 1 First Health Part D Value Plus (PDP) Standard Formulary 1 First Health Part D Premier Plus (PDP) Premier Formulary 2 Aetna Medicare Rx Premier (PDP) Premier Formulary 2 2015 MAPD State Counties MAPD Plan Name Standard 2 AL Russell, Henry, Houston Aetna Medicare Essential Plan (PPO) Standard 2 AR Benton, Carroll, Franklin, Logan, Madison, Montgomery, Pulaski, Scott, Sebastian, Washington Advantra Freedom (PPO) Premier 1 AR Crawford, Garland, Pulaski, White Advantra Premier Plus (PPO) Standard 2 AR Benton, Carroll, Crawford, Franklin, Logan, Montgomery, Scott, Sebastian, Washington Advantra Total Care (H) Premier 1 AZ Maricopa County Aetna Medicare Value Plan (H) Saver 2 CA Orange, San Diego Aetna Medicare Choice Plan (PPO) Saver 2 CA Los Angeles, Orange, San Bernardino Aetna Medicare Prime Plan (H) Saver 2 CA Los Angeles, Orange, Riverside, San Bernardino, Kern, San Diego Aetna Medicare Select Plan (H) Saver 2 CO Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson Aetna Medicare Prime Plan (H) Saver 2 CO Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson Aetna Medicare Prime Plan (PPO) Saver 2 CO Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson Aetna Medicare Select Plan (H) Standard 2 CO Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson Aetna Medicare Select Plan (PPO) Standard 2 CT Fairfield, New Haven Aetna Medicare Elite Plan (H) Saver 3 CT Fairfield, Hartford, Litchfield, New Haven, Tolland Aetna Medicare Standard Plan (H) Premier 1 CT Fairfield, Hartford, Litchfield, New Haven, Tolland Aetna Medicare Standard Plan (PPO) Premier 1 CT Hartford, Litchfield, Tolland Aetna Medicare Value Plan (H) Standard 2 DC District Of Columbia Aetna Medicare Premier Plan (PPO) Standard 2 DC District Of Columbia Aetna Medicare Standard Plan (H) Standard 2 1 of 6

DE New Castle, Kent Aetna Medicare Premier Plan (H) Standard 2 DE New Castle Aetna Medicare Premier Plan (PPO) Saver 3 DE New Castle, Kent Aetna Medicare Standard Plan (H) Standard 2 FL Hillsborough, Pinellas Aetna Medicare Premier Plan (H) Saver 1 FL Miami-Dade, Broward, Palm Beach, Charlotte, Manatee, Sarasota, Hillsborough,Pasco, Saint Johns, Duval Aetna Medicare Premier Plan (PPO) Standard 2 FL Charlotte, Lee, Manatee, Sarasota Aetna Medicare Select Plan (H) Standard 2 FL Miami-Dade, Broward, Palm Beach, Saint Johns, Duval Aetna Medicare Value Plan (H) Standard 2 FL Broward, Palm Beach, Martin, Saint Lucie, Duval, Polk, Marion Coventry Summit Ideal (H) Premier 3 FL Miami-Dade, Broward, Palm Beach, Martin, Saint Lucie, Hillsborough, Pasco, Pinellas, Polk, Marion, Duval Coventry Summit Maximum (H SNP) Premier 3 FL Miami-Dade, Saint Lucie, Hillsborough, Pinellas, Polk Coventry Summit Plus (H) Premier 3 FL Miami-Dade, Broward Coventry Vista Ideal (H) Premier 3 FL Miami-Dade Coventry Vista Maximum (H SNP) Premier 3 GA GA GA Barrow, Bryan, Burke, Camden, Chatham, Chattahoochee, Clarke, Clayton, Cobb, Columbia, Coweeta, Dekalb, Douglas, Evans, Fayette, Forsyth, Fulton, Gwinnett, Hall, Harris, Liberty, Marion, McDuffie, McIntosh, Muscogee, Newton, Paulding, Richmond, Rockdale Bryan, Chatham, Chattahoochee, Cobb, Columbia, Dekalb, Douglas, Evans, Fayette, Forsyth, Fulton, Gwinnett, Harris, Henry, Liberty, Marion, McIntosh, Muscogee, Newton, Paulding, Richmond, Rockdale Barrow, Bryan, Chatham, Chattahoochee, Clayton, Columbia, Coweeta, Dekalb, Douglas, Evans, Fayette, Forsyth, Fulton, Gwinnett, Hall, Harris, Marion, McDuffie, McIntosh, Muscogee, Newton, Paulding, Richmond, Rockdale Advantra Preferred (PPO) Premier 1 Advantra Silver (H-POS) Standard 2 Aetna Medicare Essential Plan (PPO) Standard 2 GA Cherokee, Dekalb, Forsyth, Fulton, Gwinett Aetna Medicare Select Plan (H) Saver 1 IA IA Adair, Appanoose, Benton, Boone, Bremer, Buchanan, Butler, Carroll, Cass, Cedar, Clinton, Crawford, Dallas, Decatur, Delaware, Dickinson, Fayette, Fremont, Greene, Grundy, Guthrie, Hamilton, Harrison, Ida, Iowa, Jasper, Johnson, Jones, Keokuk, Linn, Lucas, Lyon, Madison, Mahaska, Marion, Marshall, Mills, Monona, Monroe, Montgomery, Muscatine, O'Brien, Osceola, Page, Plymouth, Polk, Pottawattamie, Poweshiek, Ringgold, Scott, Shelby, Story, Sioux, Tama, Union, Warren, Washington, Wayne, Webster, Winneshiek, Woodbury, Wright Adair, Appanoose, Benton, Boone, Bremer, Buchanan, Butler, Carroll, Cass, Cedar, Crawford, Dallas, Decatur, Delaware, Fayette, Fremont, Greene, Grundy, Guthrie, Hamilton, Harrison, Ida, Iowa, Jasper, Johnson, Jones, Keokuk, Linn, Lucas, Madison, Mahaska, Marion, Marshall, Mills, Monona, Monroe, Montgomery, Muscatine, Page, Plymouth, Polk, Pottawattamie, Poweshiek, Ringgold, Scott, Shelby, Story, Tama, Union, Warren, Washington, Wayne, Webster, Winneshiek, Woodbury, Wright Coventry Advantra Platinum (PPO) Premier 1 Coventry Advantra Silver (H) Premier 1 IA Dallas, Polk, Warren, Pottawattamie Coventry Total Care (H) Premier 1 IA Marshall, Story, Ida, Monona, Plymouth, Woodbury Coventry Total Care (PPO) Premier 1 IL Tazewell, Peoria Advantra (H) Premier 1 IL Adams, Boone, Brown, Bureau, Carroll, Cass, Champaign, Christian, Coles, Cumberland, DeKalb, De Witt, Douglas, Effingham, Ford, Fulton, Hancock, Henry, Kendall, Lee, Logan, McLean, Macon, Macoupin, Marshall, Mason, Menard, Mercer, Morgan, Moultrie, Ogle, Peoria, Piatt, Pike, Rock Island, Sangamon, Scott, Shelby, Stark, Stephenson, Tazewell, Vermilion, Warren, Winnebago, Woodford, Bond, Calhoun, Clinton, Greene, Jersey, Madison, Monroe, Randolph, St. Clair, Washington Advantra (PPO) Premier 1 IL Bond, Calhoun, Clinton, Greene, Jersey, Madison, Monroe, Randolph, St. Clair, Washington Advantra Option 1 (H-POS) Premier 1 IL Bond, Calhoun, Clinton, Greene, Jersey, Madison, Monroe, Randolph, St. Clair, Washington Advantra Option 2 (H) Premier 1 IL Boone, Bureau, Carroll, DeKalb, Hancock, Henry, Kendall, Lee, Mercer, Ogle, Rock Island, Stephenson, Warren, Winnebago, Adams, Brown, Cass, Champaign, Christian, Coles, Cumberland, De Witt, Douglas, Effingham, Ford, Fulton, Logan, Macoupin, McLean, Macon, Marshall, Mason, Menard, Morgan, Moultrie, Peoria, Piatt, Pike, Sangamon, Scott, Shelby, Stark, Tazewell, Vermilion, Winnebago, Woodford Advantra Value (PPO) Saver 1 2 of 6

IL Cook Aetna Medicare Standard Plan (PPO) Standard 2 IL Cook Aetna Medicare Value Plan (H) Standard 2 IL Cook Aetna Medicare Value Plan (PPO) Saver 1 IL Boone, Winnebago, Tazewell, Peoria Coventry Total Care (H) Premier 1 IL Bond, Calhoun, Clinton, Greene, Jersey, Madison, Monroe, Randolph, St. Clair, Washington Gold Advantage (H) Premier 1 KS Wyandotte, Johnson, Miami Advantra Advantage (H) Premier 1 KS Geary, Jefferson, Riley, Shawnee, Bourbon, Douglas, Johnson, Leavenworth, Linn, Miami Advantra Freedom (PPO) Standard 2 KS Allen, Cherokee, Labette, Montgomery Advantra Freedom (PPO) Premier 1 KS Bourbon, Douglas, Johnson, Leavenworth, Linn, Miami Advantra Freedom Plus (PPO) Premier 1 KS Butler, Harvey, Sedgwick Coventry Medicare Advantage (PPO) Standard 2 KS Butler, Harvey, Sedgwick Coventry Medicare Advantage Total Care (H) Premier 1 KS Anderson, Atchison, Franklin, Jackson, Osage, Pottawatomie, Shawnee, Wabaunsee Coventry Total Care (PPO) Premier 1 KY Boone, Campbell, Kenton Aetna Medicare Select Plan (H) Standard 2 KY Boone, Campbell, Kenton Aetna Medicare Standard Plan (PPO) Standard 2 KY Boone, Campbell, Kenton Aetna Medicare Value Plan (PPO) Saver 1 LA Ascension, East Baton Rouge, Iberville, Jefferson, LaFourche, Orleans, Plaquemines, St. Tammany, Caddo Advantra (H) Premier 1 MD Frederick, Howard, Montgomery, Prince Georges Aetna Medicare Standard Plan (H) Standard 2 ME Penobscot, Oxford, Piscataquis Aetna Medicare Select Plan (H) Saver 2 ME Cumberland, York, Androscoggin, Kennebec, Sagadahoc Aetna Medicare Standard Plan (H) Standard 2 ME Cumberland, York, Androscoggin, Kennebec, Sagadahoc Aetna Medicare Value Plan (H) Standard 2 Advantra (PPO) Premier 1 Bates, Cass, Clay, Jackson, Platte Advantra Advantage (H) Premier 1 Audrain, Boone, Callaway, Cole, Crawford, Franklin, Gasconade, Jefferson, Lincoln, Miller, Moniteau, Montgomery, Osage, St. Charles, St. Louis, St. Louis City, Warren, Washington Bates, Benton, Caldwell, Carroll, Cass, Clay, Clinton, Henry, Jackson, Johnson, Lafayette, Livingston, Pettis, Platte, Ray, Saline, Vernon Barton, Jasper, McDonald, Newton, Barry, Cedar,Christian, Dade, Dallas, Douglas, Greene, Hickory, Laclede, Lawrence, Ozark, Polk, St Clair, Stone, Taney, Webster, Wright Benton, Caldwell, Carroll, Cass, Clay, Clinton, Henry, Jackson, Johnson, Lafayette, Livingston, Pettis, Platte, Ray, Saline, Vernon Advantra Dual Eligible SNP (H SNP) Standard 2 DS Advantra Freedom (PPO) Standard 2 Advantra Freedom (PPO) Premier 1 Advantra Freedom Plus (PPO) Premier 1 Barry, Cedar,Christian, Dade, Dallas, Douglas, Greene, Hickory, Laclede, Lawrence, Phelps, Polk, Pulaski, Stone, Taney, Webster, Wright Advantra Option 1 (H-POS) Premier 1 Advantra Option 2 (H) Premier 1 Coventry Advantage (H) Premier 1 3 of 6

Barry, Cedar,Christian, Dade, Dallas, Douglas, Greene, Hickory, Laclede, Lawrence, Phelps, Polk, Pulaski, Stone, Taney, Webster, Wright Coventry Advantage Plus (H-POS) Standard 2 Christian, Dade, Douglas, Greene, Lawrence, Phelps, Polk, Pulaski, Wright Coventry Premier Plus (PPO) Standard 2 Franklin, Jefferson, St. Charles, St. Louis, St. Louis City Coventry Total Care (H-POS) Premier 1 Gold Advantage (H) Premier 1 NC Alexander, Caldwell, Caswell, Catawba, Durham, Gaston, Guilford, Orange, Person, Randolph, Rockingham, Wake Advantra Gold (PPO) Premier 1 NC Alexander, Cabarrus, Caldwell, Caswell, Catawba, Durham, Gaston, Guilford, Iredell, Mecklenburg, Orange, Person, Randolph, Rockingham, Rowan, Union, Wake Aetna Medicare Premier Plan (PPO) Premier 1 NC Durham, Orange, Person, Wake Aetna Medicare Prime Plan (H) Standard 2 NC Durham, Orange, Person, Wake, Cabarrus, Gaston, Iredell, Mecklenburg, Rowan, Union Aetna Medicare Value Plan (H) Standard 2 NE Butler, Colfax, Cuming, Douglas, Gage, Jefferson, Knox, Lancaster, Washington, Wayne Coventry Advantra Platinum (PPO) Premier 1 NE Burt, Butler, Cass, Colfax, Cuming, Dodge, Douglas, Gage, Jefferson, Lancaster, Otoe, Sarpy, Saunders, Seward, Washington, Wayne Coventry Advantra Silver (H) Premier 1 NE Douglas, Sarpy Coventry Total Care (H) Premier 1 NJ Bergen, Essex, Hudson, Hunterdon, Morris, Passaic, Somertset, Sussex, Union & Warren Aetna Medicare NNJ Prime Plan (H) Saver 2 NJ Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Ocean, Passaic, Sussex, Union Aetna Medicare Premier Plan (H) Standard 2 DS NJ Atlantic, Burlington, Camden, Cumberland, Gloucester, Salem Aetna Medicare Standard Plan (H) Saver 3 NJ Essex, Hudson, Middlesex, Morris, Ocean, Passaic Aetna Medicare Standard Plan (PPO) Saver 3 NJ Ocean, Camden, Goucester, Mercer Aetna Medicare Value Plan (H) Saver 3 NV Clark Aetna Medicare Choice Plan (PPO) Saver 2 NV Clark Aetna Medicare Select Plan (H) Standard 2 NV Clark Aetna Medicare Select Plan (PPO) Standard 2 NY Livingston, Monroe, Ontario, Orleans, Seneca, Wayne, Yates Aetna Medicare Premier Plan (PPO) Saver 3 NY Bronx, Kings, Richmond Aetna Medicare Select Plan (H) Standard 2 NY Broome, Cayuga, New York, Onondaga, Oswego, Queens, Richmond, Tioga Aetna Medicare Standard Plan (PPO) Saver 3 NY Onondaga Aetna Medicare Syracuse Prime Plan (PPO) Standard 2 NY Rockland, Westchester, Broome, Cayuga, Onondaga, Oswego, Tioga Aetna Medicare Value Plan (H) Standard 2 NY New York, Queens Aetna Medicare Value Plan (H) Saver 3 NY Bronx, Kings, Richmond Aetna Medicare Value Plan (H) Standard 2 NY Broome, Cayuga, Oswego, Tioga Aetna Medicare Value Plan (PPO) Standard 2 OH Belmont, Columbiana, Cuyahoga, Geauga, Harrison, Jefferson, Lake, Mahoning, Medina, Trumbull Advantra Gold (PPO) Premier 4 OH Belmont, Columbiana, Cuyahoga, Geauga, Harrison, Jefferson, Lake, Mahoning, Medina, Trumbull Advantra Silver (PPO) Premier 4 OH Butler, Clermont, Hamilton, Hancock, Lucas, Seneca, Warren, Wood Aetna Medicare Select Plan (H) Standard 2 OH Clark, Greene, Miami, Montgomery Aetna Medicare Select Plan (H) Saver 1 4 of 6

OH Ashland, Brown, Butler, Clark, Clermont, Columbiana, Cuyahoga, Delaware, Fairfield, Franklin, Geauga, Hamilton, Hancock, Lake, Licking, Lucas, Mahoning, Marion, Medina, Miami, Muskingum, Portage, Seneca, Stark, Summit, Trumbull, Wood Aetna Medicare Standard Plan (PPO) Standard 2 OH OH Delaware, Franklin, Fairfield, Licking, Marion, Muskingum, Union, Ashland, Cuyahoga, Geauga, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull Brown, Butler, Clermont, Hamilton, Hancock, Seneca, Stark Wood, Lucas, Delaware, Franklin, Fairfield, Licking, Marion, Muskingum, Clark, Miami Aetna Medicare Value Plan (H) Standard 2 Aetna Medicare Value Plan (PPO) Saver 1 OK Oklahoma Aetna Medicare Value Plan (H) Standard 2 OK Canadian, Oklahoma Coventry Advantage (H) Saver 1 OK Canadian, Cleveland, Grady, Lincoln, Logan, Muskogee, Oklahoma, Pottawatomie, Tulsa Coventry Freedom (PPO) Standard 2 Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Butler, Carbon, Clearfield, Centre, Clinton, Columbia, Crawford, Cumberland, Dauphin, Erie, Fayette, Greene, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, Mercer, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Somerset, Sullivan, Union, Washington, Westmoreland, Wyoming, York, Bucks, Chester, Delaware, Montgomery, Philadelphia Advantra Cares (H SNP) Premier 1 DS Allegheny, Armstrong, Beaver, Bedford, Butler, Cameron, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, Mercer, Somerset, Venango, Washington, Westmoreland Allegheny, Adams, Berks, Blair, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Sullivan, Susquehanna, Union, Wayne, Wyoming, York, Delaware, Philadelphia, Buck, Chester, Montgomery Blair, Carbon, Centre, Clinton, Columbia, Huntingdon, Juniata, Lackawanna, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Schuylkill, Snyder, Sullivan, Susquehanna, Union, Wayne, Wyoming Allegheny, Adams, Armstrong, Beaver, Bedford, Berks, Butler, Blair, Cameron, Carbon, Clearfield, Centre, Clinton, Columbia, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Juniata, Indiana, Jefferson, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, Mercer, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Union, Venango, Washington, Wayne, Westmoreland, Wyoming, York Advantra Gold (H) Premier 4 Advantra Gold (PPO) Premier 4 Advantra Northern Pennsylvania Gold (H) Premier 4 Advantra Silver (H) Premier 4 Delaware, Philadelphia, Bucks, Chester, Montgomery Advantra Silver (H) Premier 1 Adams, Berks, Blair, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Sullivan, Susquehanna, Union, Wayne, Wyoming, York, Armstrong, Beaver, Bedford, Butler, Cameron, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, Mercer, Somerset, Venango, Washington, Westmoreland Advantra Silver (PPO) Premier 4 Allegheny ADNTRA SILVER (PPO) Premier 1 Cameron, Crawford, Elk, Erie, Forest, Mercer, Venango, Adams, Berks, Blair, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Indiana, Juniata, Lackawana, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Sullivan, Susquehanna, Union, Wayne, York. Adams, Berks, Blair, Carbon, Centre, Clinton, Columbia, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Schuylkill, Sullivan, Susquehanna, Union, Wayne, Wyoming, York Advantra Silver Plus (H) Premier 4 Advantra Silver Plus (PPO) Premier 4 Philadelphia Advantra UCPN Plus (H) Premier 1 5 of 6

Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Butler, Cameron, Carbon, Centre, Clearfield, Clinton, Columbia, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lycoming, Mercer, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Union, Venango, Washington, Wayne, Westmoreland, York, Wyoming AdvantraOne (PPO) Premier 1 Cumberland, Dauphin Aetna Medicare PinnacleHealth Prime Plan (H) Standard 2 Bucks, Chester, Delaware, Philadelphia, Montgomery Aetna Medicare Premier Plan (H) Standard 2 Berks, Carbon, Lancaster, Lebanon, Lehigh, Monroe, Northampton, Schuylkill Aetna Medicare Premier Plan (PPO) Standard 2 Bucks, Chester, Delaware, Philadelphia, Berks, Carbon, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Monroe, Northampton, Schuylkill, Montgomery Aetna Medicare Standard Plan (H) Standard 2 SD Bon Homme, Brookings, Clay, Hutchinson, Lake, Lincoln, McCook, Minnehaha, Moody, Turner, Union, Yankton Coventry Advantra Platinum (PPO) Premier 1 SD Lincoln, McCook, Minnehaha Coventry Total Care (PPO) Premier 1 TX Bowie, El Paso, Parker, Bexar, Fort Bend, Harris, Montgomery, Medina, Jefferson, Nueces Advantra (H) Standard 2 TX Bexar, Bowie, El Paso, Fort Bend, Harris, Montgomery, Medina, Midland, Jefferson Lubbock, Nueces, Parker Advantra (PPO) Premier 4 DS TX Bexar, Comal, Collin, Dallas, Denton, Harris, Montgomery Aetna Medicare Choice Plan (PPO) Saver 2 TX Bexar, Comal, Harris, Montgomery Aetna Medicare Premier Plan (H) Saver 2 TX Collin, Dallas, Denton Aetna Medicare Premier Plan (H) Premier 4 TX Bexar, Comal, Collin, Dallas, Denton Aetna Medicare Prime Plan (H) Saver 2 TX Atascosa, Guadaloupe, Kendall, Medina, Wilson, Ellis, Johnson, Montague, Parker, Rains, Rockwall, Brazoria, Chambers, Fort Bend, Galveston, Jefferson, Liberty, San Jacinto, Waller, Tarrant Aetna Medicare Select Plan (H) Saver 2 TX Bexar, Comal, Harris, Montgomery Aetna Medicare Value Plan (PPO) Saver 2 TX Collin, Dallas, Denton Aetna Medicare Value Plan (PPO) Premier 4 UT Box Elder Cache, Daggett, Davis, Duchesne, Morgan, Rich, Salt Lake, Summit, Tooele, Uintah, Utah, Wasatch, Weber Altius Advantra (H) Standard 2 WV Chesterfield, Hanover, Henrico, Richmond City, Danville City, Henry, Martinsville City, Pittsylvania, Gloucester, Hampton City, Newport News City, York Alexandria City, Arlington, Fairfax, Fairfax City, Falls Church City, Loudoun, Manassas City, Manassas Park City, Prince William Alexandria City, Arlington, Fairfax, Fairfax City, Falls Church City, Loudoun, Manassas City, Manassas Park City, Prince William Chesterfield, Hanover, Henrico, Richmond City, Danville City, Henry, Martinsville City, Pittsylvania, Gloucester, Hampton City, Newport News City, York Berkeley, Brooke, Doddridge, Grant, Hampshire, Hancock, Hardy, Harrison, Jefferson, Lewis, Marion, Marshall, Monongalia, Morgan, Ohio, Preston, Randolph, Taylor, Tucker, Upshur, Wetzel, Boone, Braxton, Cabell, Clay, Fayette, Gilmer, Greenbrier, Jackson, Kanawha, Lincoln, Logan, Mason, Mercer, Nicholas, Putnam, Raleigh, Ritchie, Wayne, Wirt, Wood, Wyoming Aetna Medicare Essential Plan (PPO) Standard 2 Aetna Medicare Innovation Choice Plan (PPO) Standard 2 Aetna Medicare Innovation Prime Plan (H) Standard 2 Aetna Medicare Select Plan (H) Saver 3 Advantra Gold (PPO) Premier 4 WV Berkeley, Brooke, Doddridge, Grant, Hampshire, Hancock, Hardy, Harrison, Jefferson, Lewis, Marion, Marshall, Monongalia, Morgan, Ohio, Preston, Randolph, Taylor, Tucker, Upshur, Wetzel, Boone, Braxton, Cabell, Clay, Fayette, Gilmer, Greenbriar, Jackson, Kanawha, Lincoln, Logan, Mason, Mercer, Nicholas, Putnam, Raleigh, Ritchie, Wayne, Wirt, Wood, Wyoming Advantra Silver (H) Premier 4 WY Uinta Altius Advantra (H) Standard 2 Producers must be licensed in the applicable state, appointed by Aetna and/or Coventry, and certified prior to engaging in the sale of Aetna or Coventry products. This communication is intended for use by producers only and is not intended for distribution to Medicare beneficiaries. Any publication or distribution of this communication to unauthorized recipients without Aetna s approval is prohibited. 6 of 6