As a GOLD member: I understand that, beginning on the date my Gold coverage begins, I must get all of my health care from the Gold plan, with the exception of emergency or urgently needed service, out-of-network dialysis services or services payable under the Travel Benefit. In addition to being covered in the United States, emergency and urgently needed services are covered worldwide. I understand that services authorized by Preferred Care and other services contained in my Gold plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. I also understand that without authorization, NEITHER MEDICARE NOR PREFERRED CARE WILL PAY FOR THE SERVICES that require authorization.

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As a GOLDANYWHERE member: I understand that, beginning on the date my GoldAnywhere coverage begins, I may get all of my health care from GoldAnywhere network providers, or at greater costs to me, from non-network providers, with the exception of emergency or urgently needed services or out-of-network dialysis, which cost me the same regardless of whether the services are provided by a network or non-network provider. I understand that services authorized by Preferred Care and other services contained in my GoldAnywhere plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. I also understand that I am ultimately responsible for ensuring that authorization is obtained for services which require authorization and that I will incur a financial penalty when required authorization is not obtained.

By joining this plan, I attest that I am not receiving any financial support from my current or former employer group or union (or my spouse’s current or former employer group or union) intended for the purchase of prescription drugs or prescription drug coverage or to pay for, in whole or in part, my enrollment in a Medicare drug plan.