Appendix D

Blue Medicare Advantage HMO Contracted Providers

Ambulatory Surgicenters ………………………………………………………... 2

Durable Medical Equipment ……………………………………………………... 3

Home Health Care ………………………………………………………………... 4

Home Infusion ……………………………………………………………………. 6

Hospice …………………………………………………………………………… 7

Inpatient – Metro Hospitals ………………………………………………………. 8

Long Term Acute Care ………………………………………………………….. 12

Mental Health IP/OP …………………………………………………………….. 13

Orthotic & Prosthetic …………………………………………………………….. 14

Hospital Based Outpatient Surgery ………………………………………………. 17

Renal Dialysis ……………………………………………………………………. 20

Skilled Nursing Facilities ………………………………………………………… 27

Substance Use Disorder ………………………………………………………… 32

A Division of Healthcare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date

Surgicenter 01/01/2013 Center for Reconstructive Surgery 6309 W 95th St Oak Lawn IL 60453 (708) 499-3355

Surgicenter 01/01/2013 DMG Pain Management Surgery Ct 2940 Rolling Ridge Rd. Naperville IL 60564 (630) 303-5304 A 11/26/12

Surgicenter 01/01/2013 DMG Surgical Center, LLC 2725 S. Technology Drive Lombard IL 60148 (630) 942-7998 60126- Surgicenter 01/01/2013 Elmhurst Outpatient Surgery 1200 S. York Road Elmhurst IL 5626 (630) 758-8457 Novamed Surgery Ct of Chicago Northshore Surgicenter 01/01/2013 LLG 3034 W. Peterson Ave. Chicago IL 60659 (773) 973-7432 A 11/26/12

Novamed Surgery Ct of Oak Lawn d/b/a/ Surgicenter 01/01/2013 Center for Reconstructive Surgery 6311 W. 95th St. Oak Lawn IL 60453 (708) 499-3355 A 11/26/12

Surgicenter 01/01/2013 Novamed Surgery Ct of River Forest 7427 Lake St. River Forest IL 60305 (708) 771-3334 A 11/26/12

Surgicenter 01/01/2013 NW Community Day Surgery 675 West Kirchoff Road Arlington Hgts IL 60008 (847) 618-1000 Pain Management Surgical Center of 2940 Rolling Ridge Road, Suite Surgicenter 01/01/2013 DuPage Medical Group 200 Naperville IL 60564 (630) 697-6000 A 11/01/12 Surgicenter 01/01/2013 Resurrection Health Care Surgery Center 3115 N. Harlem Avenue Chicago IL 60634 (773) 889-2000 Surgicenter 01/01/2013 Surgical Center of DuPage Medical Group 2725 Technology Drive Lombard Il 60148 (630) 348-3300 A 11/01/12 Surgicenter 01/01/2013 United Shockwave Therapies - West 120 N. LaGrange Road LaGrange IL 60525 (708) 352-6666 A 11/06/12 Surgicenter 01/01/2013 United Shockwave Therapies-North 1875 W. Dempster Street Park Ridge IL 60068 (847) 696-2210

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Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date

DME 01/01/2013 Apria Health Care 4055 Steele Dr. Machesney Pk IL 61115 (847) 252-2000

DME 01/01/2013 Apria Health Care 1015 W. Deitweiller Drive Peoria IL 61615 (309) 691-1012

DME 01/01/2013 Apria Health Care 1581 E. 90th Place Merrillville IN 46410 (219) 736-1302

DME 01/01/2013 Apria Health Care 775 E. Linton Ave. Springfield IL 62703 (217) 789-0461 60515- DME 01/01/2013 Byram HealthCare 3010 Woodcreek Dr Downers Grove IL 5415 (800) 681-1395 DME 01/01/2013 Delnor Comm. Hosp. Home Hlth 300 Randall Road Geneva IL 4200 (630) 513-0370 Dupage Medical Group dba Premier DME 01/01/2013 Medical Equipment 428 Pennsylvania Ave Glen Ellyn IL 60137 (630) 545-7770

DME 01/01/2013 Edgepark Medical Supplies 1360 Madeline Lane Elgin IL 60124 (800) 307-5930 Elmhurst Memorial Home Health DME dba DME 01/01/2013 Action Medical Equipment 855 N. Church Center Elmhurst IL 60126 (630) 758-7000

DME 01/01/2013 Resurrection Services 5747 W. Dempster Morton Grove IL 60053 (847) 568-8500 DME 01/01/2013 United Seating and Mobility 335 Eisenhower Lane So Lombard IL 60148 A 11/02/12

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4 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date

Home Health 01/01/2013 Advocate Home Health Care 2311 W. 22nd Street Oak Brook IL 60523 (630) 572-1232

Home Health 01/01/2013 Alexian Brothers Home Health 1515 E. Lake Street Hanover Park IL 60133 (847) 437-5500 60188 Home Health 02/01/2014 CNS HOME HEALTH & HOSPICE 690 E NORTH AVE STE 100 CAROL STREAM IL 2172 6306657000 ONE MERCHANTS PLAZA STE 60543 Home Health 02/01/2014 COMMUNITY ALLIANCE HOME HEALTH 202 OSWEGO IL 9453 6308980122 60134- Home Health 01/01/2013 Delnor Community Hosp. HHA 300 Randall Road Geneva IL 4200 (630) 513-0370

Home Health 01/01/2013 Elmhurst Memorial HomeHealth 855 N. Church Court Elmhurst IL 60126 (630) 530-1201

Home Health 01/01/2013 Interim HealthCare 10735 S Cicero, Suite 100 Oak Lawn IL 60453 (708) 422-2934 Mt. Sinai Hospital & Med. Ctr. Home Health Home Health 01/01/2013 03/01/2013 Care 15th at California Chicago IL 60605 (773) 542-2000 60464- Home Health 01/01/2013 01/01/2013 New Beginnings Home Health Care 13011 S 104th St, Suite 205 Palos Park IL 1512 (708) 671-1700 C 01/01/2013

Home Health 01/01/2013 Northwest Comm. Hosp. Home Care 3060 Salt Creek Lane Arlington Hgts IL 60005 (847) 618-1000

Home Health 01/01/2013 Palos Community Hosp. Home Health 15295 E. 127th Street Lemont IL 60439 (630) 257-1111

Home Health 01/01/2013 Private Home Care Unlimited 5517 N. Cumberland Chicago IL 60656 (773) 467-6000 60435- Home Health 01/01/2013 Provena Home Health Joliet 1060 Essington Road Joliet IL 8200 (815) 741-7371 60914- Home Health 01/01/2013 Provena Home Health Kankakee 179 E. Bethel Bourbonnais IL 1456 (815) 937-2475 61822- Home Health 01/01/2013 11/30/2013 Provena Home Health Urbana 1501 Interstate Drive Champaign IL 1006 (217) 355-4120

Home Health 01/01/2013 Provena Home Health Waukegan 222 S. Greenleaf Ave. Waukegan IL 60031 (847) 360-7660

Home Health 01/01/2013 Provena St. Joseph (Elgin) 799 South McLean Blvd. Elgin IL 60123 (847) 622-2055

Home Health 01/01/2013 Residentail Home Health Illinois 40 Shuman Blvd, Suite 204 Naperville IL 60563 (630) 527-6830 60016- Home Health 01/01/2013 Resurrection Home Health Services 2380 E Dempster St Des Plaines IL 4839 (847) 493-4800

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Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 60901- Home Health 01/01/2013 01/01/2013 RMC Home Health Care 1905 W. Court Street Kankakee IL 3163 (815) 935-3272

Home Health 01/01/2013 12/09/2013 Sherman Home Care Partners 1019 E. Chicago Street Elgin IL 60120 (847) 429-6200

Home Health 01/01/2013 Sherman Home Care Partners 901 Center Street, Suite 2001A Elgin IL 60120 (224) 783-6200

Home Health 01/01/2013 Silver Cross Home Health 1200 Maple Road Joliet IL 60432 (815) 740-7124

Home Health 01/01/2013 Swedish Covenant Hospital HH 2965 W. Peterson Ave. Chicago IL 60659 (773) 275-9700

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6 Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date

Home HIT 01/01/2013 Advocate Home Care Products 1441 Branding Lane, Suite 310 Downers Grove IL 60515 (630) 963-3200

Home HIT 01/01/2013 Alexian Brothers Home Health 1515 Lake Street Hanover Park IL 60133 (847) 956-5464

Home HIT 01/01/2013 Coram Health Care Corp. of IN 1290 Arrowhead Ct. Crown Point IN 46307 (219) 661-0272

Home HIT 01/01/2013 Coram HealthCare Corp of IL 1471 E. Business Center Dr. Mt. Prospect IL 60056 (847) 294-6422

Home HIT 01/01/2013 Elmhurst Mem Hosp Home Infusion 200 Berteau Avenue Elmhurst IL 60126 (630) 993-5165

Home HIT 01/01/2013 Loyola Univ Med Ctr Home Care 2160 S. First Avenue Maywood IL 60153 (708) 216-4983

Home HIT 01/01/2013 MacNeal Infusion Therapy 3249 S. Oak Park Ave. Berwyn IL 60402 (708) 447-3555 5517 N Cumberland Ave, Suite Home HIT 01/01/2013 Pri Med Infusion Services 915 Chicago IL 60656 (773) 467-6000

Home HIT 01/01/2013 Sherman Home Care Partners 901 Center Street, Suite 2001A Elgin IL 60120 (224) 783-6200

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7 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Stat Change Provider Type Effective Date Cancel Date Provider Name Address City e Zip Telephone Code Change Date 60123 Hospice 01/01/2013 PRESENCE HOSPICE ELGIN 799 S MCLEAN BLVD STE 101 ELGIN IL 6702 8479315553

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8 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Inpatient - 60440 Metro 01/01/2014 ADVENTIST BOLINGBROOK HOSPITAL 500 REMINGTON BLVD BOLINGBROOK IL 4906 6303125000 Inpatient - 60139 Metro 01/01/2014 ADVENTIST GLEN OAKS HOSPITAL 701 WINTHROP AVE GLENDALE HEIGHTS IL 1405 6305458000 Inpatient - 60521 Metro 01/01/2014 ADVENTIST HINSDALE HOSPITAL 120 N OAK ST HINSDALE IL 3829 6308569000 Inpatient - 60525 Metro 01/01/2014 ADVENTIST LAGRANGE MEMORIAL HOSP 5101 S WILLOW SPRINGS RD LA GRANGE IL 2600 7083521200 Inpatient - 60048- Metro 01/01/2013 Advocate Condell Medical Center 801 S. Milwaukee Avenue Libertyville IL 3204 (847) 362-2900 Inpatient - 60657- Metro 01/01/2013 Advocate Illinois Masonic Medical Center 836 Wellington Ave. Chicago IL 5147 (773) 975-1600 Inpatient - 60194- Metro 01/01/2013 Alexian Brothers Behavioral Health Hospital 1650 Moonlake Blvd. Hoffman Estates IL 1010 (847) 882-1600 Inpatient - 60007- Metro 01/01/2013 Alexian Brothers Medical Center 800 West Biesterfield Road Elk Grove Village IL 3311 (847) 437-5500 Inpatient - Metro 01/01/2013 Central DuPage Hospital 25 North Winfield Road Winfield IL 60190 (630) 682-1600 Inpatient - 60453- Metro 01/01/2013 Christ Hosp. & Med. Ctr. - Advocate 4440 West 95th Street Oak Lawn IL 2600 (708) 684-8000 Inpatient - 60134- Metro 01/01/2013 Delnor Community Hospital 300 Randall Road Geneva IL 4200 (630) 208-3000 Inpatient - 60540- Metro 01/01/2013 Edward Hospital 801 South Washington Street Naperville IL 7430 (630) 355-0450 Inpatient - 60126- Metro 01/01/2013 Elmhurst Memorial Hospital 155 East Brush Hill Rd Elmhurst IL 5658 (630) 833-1400 Inpatient - 60026 Metro 01/01/2014 GLENBROOK HOSPITAL 2100 PFINGSTEN RD GLENVIEW IL 1301 8476575800 Inpatient - 60515- Metro 01/01/2013 Good Samaritan Hospital - Advocate 3815 Highland Avenue Downers Grove IL 1500 (630) 275-5900 Inpatient - Metro 01/01/2013 Good Shepherd Hospital - Advocate 450 West Highway 22 Barrington IL 60010 (847) 381-9600 Inpatient - 60035 Metro 01/01/2014 HIGHLAND PARK HOSPITAL 777 PARK AVE WEST HIGHLAND PARK IL 2433 8474328000 Inpatient - 60629 Metro 01/01/2014 HOLY CROSS HOSPITAL 2701 W 68TH ST CHICAGO IL 1813 7738849000 Inpatient - 60540- Metro 01/01/2013 Linden Oaks Hospital 852 West Street Naperville IL 6400 (630) 305-5500

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Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Inpatient - 60640- Metro 01/01/2013 Louis A. Weiss Memorial Hospital 4646 North Marine Drive Chicago IL 5700 (773) 878-8700 Inpatient - 60153- Metro 01/01/2013 Loyola University Med. Ctr. 2160 South First Ave. Maywood IL 3304 (708) 216-9000 Inpatient - 60068- Metro 01/01/2013 Lutheran General Hospital 1775 Dempster Street Park Ridge IL 1143 (847) 723-2210 Inpatient - 60402- Metro 01/01/2013 MacNeal Memorial Hospital 3249 S. Oak Park Ave. Berwyn IL 3429 (708) 783-9100 Inpatient - 60187 Metro 05/01/2013 MARIANJOY REHABILITATION HOSPITAL 26 W 171 ROOSEVELT RD WHEATON IL 6078 6309098000 Inpatient - 60608- Metro 01/01/2013 Mount Sinai Hospital Medical Center California Avenue at 15th St. Chicago IL 1797 (773) 542-2000 Inpatient - 60201 Metro 01/01/2014 NORTHSHORE UNIVERSITY HEALTHSYSTE 2650 RIDGE AVE EVANSTON IL 1718 8475705020 Inpatient - 60005- Metro 01/01/2013 Northwest Community Health Care 800 W. Central Rd. Arlington Hgts IL 2349 (847) 618-1000 Inpatient - 60634- Metro 01/01/2013 Our Lady of the Resurrection Med. Ct. 5645 W. Addison Street Chicago IL 4403 (773) 282-7000 Inpatient - 60463- Metro 01/01/2013 Palos Community Hospital 12251 South 80th Ave. Palos Heights IL 1256 (708) 923-4000 Inpatient - 60631- Metro 01/01/2013 Presence Resurrection Medical Center 7435 West Talcott St. Chicago IL 3702 (773) 774-8000 Inpatient - 60506- Metro 01/01/2013 Provena Mercy Medical Center 1325 North Highland Ave. Aurora IL 1449 (630) 859-2222 Inpatient - 60123- Metro 01/01/2013 Provena St. Joseph Hospital 77 North Airlite Street Elgin IL 4912 (847) 695-3200 Inpatient - Metro 01/01/2013 Provena St. Joseph Med. Center 333 North Madison St. Joliet IL 60435 (815) 725-7133 Inpatient - 60901- Metro 01/01/2013 Provena St. Mary's Hospital 500 W. Court S. Kankakee IL 3661 (815) 937-2490 Inpatient - 60624 Metro 06/01/2013 RML CHICAGO 3435 W VAN BUREN CHICAGO IL 3312 6302864000 Inpatient - 60521 Metro 06/01/2013 RML SPECIALTY HOSPITAL 5601 S COUNTY LINE RD HINSDALE IL 4875 6302864223 Inpatient - 60504- Metro 01/01/2013 Rush Copley Memorial Hosp. 2000 Ogden Ave. Aurora IL 7222 (630) 978-6200 Inpatient - Metro 01/01/2013 Saint Joseph Hospital 2900 North Lake Shore Dr. Chicago IL 60657 (773) 665-3000

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10 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Inpatient - 60608- Metro 01/01/2013 Schwab Rehabilitation Hospital 1401 S. California Ave. Chicago IL 1612 (773) 522-2010 Inpatient - 60120- Metro 01/01/2013 Sherman Hospital 1425 N Randall Road Elgin IL 2125 (847) 742-9800 Inpatient - 60451- Metro 01/01/2013 Silver Cross Hospital 1900 Silver Cross Blvd New Lenox IL 9508 (815) 300-1100 Inpatient - 60076 Metro 01/01/2014 SKOKIE HOSPITAL 9600 GROSS POINT RD SKOKIE IL 1214 8476779600 Inpatient - 60429- Metro 01/01/2013 South Suburban Hospital - Advocate 17800 S. Kedzie Ave. Hazel Crest IL 2029 (708) 799-8000 Inpatient - 60194- Metro 01/01/2013 St. Alexius Med. Center 1555 N. Barrington Rd. Hoffman Estates IL 1018 (847) 843-2000 Inpatient - 60621- Metro 01/01/2013 St. Bernard Hospital 326 West 64th Street Chicago IL 3119 (773) 962-3900 Inpatient - 60622- Metro 01/01/2013 St. Elizabeth Hospital (Chicago) 1431 N. Claremont Ave. Chicago IL 1702 (773) 278-2000 Inpatient - 60202- Metro 01/01/2013 St. Francis Hospital (Evanston) 355 Ridge Avenue Evanston IL 3328 (847) 316-4000 Inpatient - 60622- Metro 01/01/2013 St. Mary and Elizabeth Medical Center 2233 W. Division Street Chicago IL 3043 (312) 770-2000 Inpatient - 60625- Metro 01/01/2013 Swedish Covenant Hospital 5145 N. California Ave. Chicago IL 3642 (773) 878-8200 Inpatient - 60617- Metro 01/01/2013 Trinity Hospital - Advocate 2320 East 93rd Street Chicago IL 3909 (773) 978-2000 Inpatient - 60637- Metro 01/01/2013 University of Chgo. Med. Center 5841 Maryland Ave. Chicago IL 1463 (773) 702-1000 Inpatient - 60302- Metro 01/01/2013 West Suburban Hospital 3 Erie Court Oak Park IL 2510 (708) 383-6200 Inpatient - 60160- Metro 01/01/2013 Westlake Community Hospital 1225 West Lake Street Melrose Park IL 4021 (708) 671-3000

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11 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

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12 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Long Term Acute Care 01/01/2013 Holy Family Medical Center 100 North River Road Des Plaines IL 60016 (847) 297-1800

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13 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Holy Family Medical Center/ Key's to Mental Health 01/01/2013 Recovery 100 N River Rd. Des Plaines IL 60016 (847) 298-9355 A 11/26/12

Mental Health 01/01/2013 Resurrection Behavioral Health - Respite 117 S 6th Ave. Maywood IL 60153 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at Holy Mental Health 01/01/2013 Family Med Ct 100 North River Road. Des Plaines IL 60016 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at Our Lady Mental Health 01/01/2013 of the Resurrection Med Ct 5645 W. Addison St. Chicago IL 60634 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at Pillares Mental Health 01/01/2013 (Berwyn) 6918 Windsor Avenue, Suite 410 Berwyn IL 60402 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at ProCare Mental Health 01/01/2013 (Broadview) 1820 S 25th Ave Broadview IL 60155 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at ProCare Mental Health 01/01/2013 (Melrose Pk) 1414 Main St. Melrose Park IL 60160 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at ProCare Mental Health 01/01/2013 (Westchester) 9855 Roosevelt Rd Westchester IL 60154 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at ProCare Mental Health 01/01/2013 (Westchester) 9845 Roosevelt Rd Westchester IL 60154 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at Mental Health 01/01/2013 Resurrection Med Ct 7435 W. Talcott Ave. Chicago IL 60631 (708) 410-0615 A 11/26/12 Resurrection Behavioral Health at Saint Mental Health 01/01/2013 Francis Hospital 355 Ridge Ave Evanston IL 60202 (708) 410-0615 A 11/26/12

Mental Hlth - IP 01/01/2013 Saint Joseph Behavioral Health 2900 N Lake Shore Dr Chicago IL 60657 (773) 665-3000 A 11/26/12

Mental Hlth - IP 01/01/2013 Saints Mary and Elizabeth Medical Center 2233 W Division St Chicago IL 60622 (312) 770-2000 A 11/26/12

Mental Hlth - OP 01/01/2013 Saint Joseph Behavioral Health 2913 N Commonwealth Dr. Chicago IL 60657 (773) 665-3000 A 11/26/12

Mental Hlth - OP 01/01/2013 Saints Mary and Elizabeth Medical Center 1431 N. Claremont Chicago IL 60622 (312) 633-5890 A 11/26/12

Mental Hlth - OP 01/01/2013 Saints Mary and Elizabeth Medical Center 1127 N Oakley Chicago IL 60622 (312) 770-2317 A 11/26/12

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14 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

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15 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics & Orthotics 7 Bronze Pointe South Belleville IL 62226 (618) 222-7032 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics & Orthotics (Herrin, IL) 404 Rushing Drive Herrin IL 62948 (618) 997-1451 Orthotic & Hanger Prosthetics & Orthotics (Orland Prosthetic 01/01/2013 Park) 10719 W. 160th Street Orland Park IL 60467 (708) 364-1570 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics & Orthotics (Peoria) 719 N. Kumpf Blvd. Peoria IL 61605 (309) 637-6581 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics & Orthotics (Quincy) 325 S. Eighth Ave. Quincy IL 62301 (217) 222-3680 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics & Orthotics (Springfield) 1101 No 9th Street Springfield IL 62702 (217) 523-9679 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics & Orthotics (St. John IN) 8626 Wicker Ave. St. John IN 46373 (219) 365-1424 Orthotic & 60443- Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics 4525 W. Lincoln Highway Matteson IL 2318 (708) 755-2200 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics 415 N. Main Street Decatur IL 62523 (217) 429-6656 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics 1123 Emerson Street Evanston IL 60201 (847) 864-7711 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics 75 Market Place Elgin IL 60123 (847) 695-6955 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics 215 N. Convent Street Bourbonnais IL 60914 (815) 937-0241 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics (Aurora) 4255 Westbrook Dr. Aurora IL 60504 (630) 820-5673 Orthotic & Hanger Prosthetics and Orthotics Prosthetic 01/01/2013 (Crestwood.) 13443 S. Cicero Crestwood IL 60455 (708) 371-9999 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics (Gurnee) 35 Tower Court Street Gurnee IL 60031 (847) 623-6080 Orthotic & Hanger Prosthetics and Orthotics Prosthetic 01/01/2013 (Hammond) 7324 Indianapolis Blvd Hammond IN 46324 (219) 844-2021 Orthotic & Hanger Prosthetics and Orthotics (Hazel 60429- Prosthetic 01/01/2013 Crest) 17530 S. Kedzie Avenue Hazel Crest IL 2004 (708) 957-0240 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics (Joliet) 330 N. Madison Street Joliet IL 60435 (815) 744-9944 Orthotic & Hanger Prosthetics and Orthotics Prosthetic 01/01/2013 (Libertyville) 624 E. Park Ave. Libertyville IL 60048 (847) 367-6572

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Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Orthotic & Hanger Prosthetics and Orthotics (McHenry, Prosthetic 01/01/2013 IL) 620 S. Route 31 McHenry IL 60050 (815) 344-3070 Orthotic & Hanger Prosthetics and Orthotics Prosthetic 01/01/2013 (Merrillville, IN) 8691 Connecticut Merrillville IN 46410 (219) 793-1900 Orthotic & Prosthetic 01/01/2013 Hanger Prosthetics and Orthotics (Morris) 1051 W. US Route 6 Morris IL 60450 (708) 957-0240 Orthotic & Hanger Prosthetics and Orthotics Prosthetic 01/01/2013 (OakBrook, IL) 1S224 Summit Ave. Oak Brook Terrace IL 60181 (630) 620-5333 Orthotic & Hanger Prosthetics and Orthotics (Portage, 46368- Prosthetic 01/01/2013 IN.) 6375 U S Highway 6 Portage IN 5111 (219) 887-5101 Orthotic & Hanger Prosthetics and Orthotics(Mt. Prosthetic 01/01/2013 Vernon, IL) 301 Main Street Mt Vernon IL 62864 (618) 244-9456 Orthotic & Hanger Prosthetics and Orthotics(North Prosthetic 01/01/2013 Riverside) 7222 W. Cermak Road North Riverside IL 60546 (708) 447-9860 Orthotic & Hanger Prosthetics and OrthoticsPeterson Prosthetic 01/01/2013 Ave. (Chg) 4801 W. Peterson Ave. Chicago IL 60646 (773) 777-9494 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 617 E Golf Road, Suite 108 Arlington Hgts IL 60005 (847) 437-3929 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 1551 Bond St, Suite 111 Naperville IL 60563 (630) 637-4638 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 8641 W. 95th St. Hickory IL 60457 (708) 599-8336 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 1725 W Harrison St, Suite 829 Chicago IL 60612 (312) 942-2011 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 2530 Crawford Ave, Suite 218 Evanston IL 60201 (847) 475-7080 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 2552 N Clark St, Suite 200 Chicago IL 60614 (773) 472-3663 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 2101 Waukegan Road, Suite 104 Bannockburn IL 60015 (847) 444-0690 Orthotic & 1740 W Taylor St, Room C100, Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc MC889 Chicago IL 60612 (312) 996-6450 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 401 Harrison St Oak Park IL 60304 (708) 383-2257 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 6629 W Lincoln Hwy, Suite One Schereville IN 46375 (219) 864-9502 Orthotic & Prosthetic 01/01/2013 Scheck & Siress Prosthetics, Inc 1S376 Summit Ave, Court E Oakbrook Terrace IL 60181 (630) 424-0392

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Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date

A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

Rev. 7-2014

18 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Outpatient 60048- Surgery 01/01/2013 Advocate Condell Medical Center 801 S. Milwaukee Avenue Libertyville IL 3204 (847) 362-2900 Outpatient 60657- Surgery 01/01/2013 Advocate Illinois Masonic Medical Center 836 Wellington Ave. Chicago IL 5147 (773) 975-1600 Outpatient 60194- Surgery 01/01/2013 Alexian Brothers Behavioral Health Hospital 1650 Moonlake Blvd. Hoffman Estates IL 1010 (847) 882-1600 Outpatient 60007- Surgery 01/01/2013 Alexian Brothers Medical Center 800 West Biesterfield Road Elk Grove IL 3311 (847) 437-5500 Outpatient Surgery 01/01/2013 Central DuPage Hospital 25 North Winfield Road Winfield IL 60190 (630) 682-1600 Outpatient 60453- Surgery 01/01/2013 Christ Hospital 4440 West 95th Street Oak Lawn IL 2600 (708) 684-8000 Outpatient 60134- Surgery 01/01/2013 Delnor Community Hospital 300 Randall Road Geneva IL 4200 (630) 208-3000 Outpatient 60540- Surgery 01/01/2013 Edward Hospital 801 South Washington Street Naperville IL 7430 (630) 833-1400 Outpatient 60126- Surgery 01/01/2013 Elmhurst Memorial Hospital 200 Berteau Avenue Elmhurst IL 2966 (630) 833-1400 Outpatient 60515- Surgery 01/01/2013 Good Samaritan Hospital - Advocate 3815 Highland Avenue Downers Grove IL 1500 (630) 275-5900 Outpatient Surgery 01/01/2013 Good Shepherd Hospital - Advocate 450 West Highway 22 Barrington IL 60010 (847) 381-9600 Outpatient 60016- Surgery 01/01/2013 Holy Family Medical Center 100 North River Road Des Plaines IL 1209 (847) 297-1800 Outpatient 60640- Surgery 01/01/2013 Louis A. Weiss Memorial Hospital 4646 North Marine Drive Chicago IL 5700 (708) 216-9000 Outpatient 60153- Surgery 01/01/2013 Loyola University Med. Ctr. 2160 South First Ave. Maywood IL 3304 (708) 216-9000 Outpatient 60068- Surgery 01/01/2013 Lutheran General Hospital 1775 Dempster Street Park Ridge IL 1143 (847) 723-2210 Outpatient 60402- Surgery 01/01/2013 MacNeal Hospital 3249 S. Oak Park Ave. Berwyn IL 3429 (708) 783-9100 Outpatient 60608- Surgery 01/01/2013 Mount Sinai Hospital California Avenue at 15th Street Chicago IL 1797 (773) 542-2000 Outpatient 60005- Surgery 01/01/2013 Northwest Community Hospital 800 W. Centtral Rd. Arlington Hgts IL 2349 (847) 618-1000 Outpatient 60634- Surgery 01/01/2013 Our Lady of the Resurrection 5645 W. Addison Street Chicago IL 4403 (773) 282-7000

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19 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Outpatient 60463- Surgery 01/01/2013 Palos Community 12251 South 80th Ave. Palos Hgts IL 1256 (708) 923-4000 Outpatient 60631- Surgery 01/01/2013 Presence Resurrection Medical Center 7435 West Talcott St. Chicago IL 3702 (773) 774-8000 Outpatient 60123- Surgery 01/01/2013 Provena Mercy Medical Center (Aurora) 1325 North Highland Ave. Elgin IL 4912 (815) 725-7133 Outpatient Surgery 01/01/2013 Provena St. Joseph Med. Center(Joliet) 333 North Madison St. Joliet IL 60435 (815) 725-7133 Outpatient 60504- Surgery 01/01/2013 Rush-Copley Medical Center 2000 Ogden Ave. Aurora IL 7222 (630) 978-6200 Outpatient 60608- Surgery 01/01/2013 Schwab Rehabilitation Hospital 1401 S. California Ave. Chicago IL 1612 (773) 522-2010 Outpatient Surgery 01/01/2013 Sherman Hospital 1425 N Randall Road Elgin IL 60123 (847) 742-9800 Outpatient 60432- Surgery 01/01/2013 Silver Cross Hospital 1200 Maple Road Joliet IL 1439 (815) 740-1100 Outpatient 60429- Surgery 01/01/2013 South Suburban Hospital - Advocate 17800 S. Kedzie Ave. Hazel Crest IL 2029 (708) 799-8000 Outpatient 60194- Surgery 01/01/2013 St. Alexius Med. Center 1555 N. Barrington Rd. Hoffman Estates IL 1018 (847) 843-2000 Outpatient 60621- Surgery 01/01/2013 St. Bernard Hospital 326 West 64th Street Chicago IL 3119 (773) 962-3900 Outpatient 60622- Surgery 01/01/2013 St. Elizabeth Hospital (Chicago) 1431 N. Claremont Ave. Chicago IL 1702 (773) 278-2000 Outpatient 60202- Surgery 01/01/2013 St. Francis Hospital (Evanston) 355 Ridge Avenue Evanston IL 3328 (847) 492-4000 Outpatient 60123- Surgery 01/01/2013 St. Joseph (Elgin) 77 North Airlite Street Elgin IL 4912 (847) 695-3200 Outpatient 60657- Surgery 01/01/2013 St. Joseph Hospital 2900 North Lake Shore Dr. Chicago IL 5640 (773) 665-3000 Outpatient 60622- Surgery 01/01/2013 St. Mary and Elizabeth Medical Center 2233 W. Division Street Chicago IL 3043 (312) 770-2000 Outpatient 60901- Surgery 01/01/2013 St. Mary's Hospital 500 W. Court S. Chicago IL 3661 (815) 937-2490 Outpatient 60625- Surgery 01/01/2013 Swedish Covenant 5145 N. California Ave. Chicago IL 3642 (773) 878-8200 Outpatient 60617- Surgery 01/01/2013 Trinity Hospital - Advocate 2320 East 93rd Street Chicago IL 3909 (773) 978-2000

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20 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Outpatient 60637- Surgery 01/01/2013 University of Chgo. Med. Center 5841 Maryland Ave. Chicago IL 1463 (773) 702-1000 Outpatient 60302- Surgery 01/01/2013 VHS West Suburban Medical Center 3 Erie Court Oak Park IL 2510 (708) 383-6200 Outpatient 60160- Surgery 01/01/2013 VHS Westlake Hospital Inc 1225 West Lake Street Melrose Park IL 4021 (847) 681-3000 Outpatient 60302- Surgery 01/01/2013 West Suburban Hospital 3 Erie Court Oak Park IL 2510 (708) 383-6200 Outpatient 60160- Surgery 01/01/2013 Westlake Community Hospital 1225 West Lake Street Melrose Park IL 4021 (847) 681-3000

A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

Rev. 7-2014

21 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Renal Dialysis 01/01/2013 Aurora Dialysis Center 455 Mercy Ln Aurora IL 60506

Renal Dialysis 01/01/2013 Austin Community Kidney Center 4800 W Chicago Ave, Suite 2A Chicago IL 60651 60620 Renal Dialysis 02/01/2014 BEVERLY DIALYSIS 8109 SOUTH WESTERN AVE CHICAGO IL 5939 7732385200 60714 Renal Dialysis 02/01/2014 BIG OAKS DIALYSIS 5623 W TOUHY AVE NILES IL 4019 8476473140 60641 Renal Dialysis 01/01/2013 08/31/2013 BMA BELMONT 4943 W BELMONT AVE CHICAGO IL 4332 7736857500 Renal Dialysis 01/01/2013 Champaign Urbana Dialysis Center 1400 W Park St Urbana IL 61801 Renal Dialysis 01/01/2013 Chicago Dialysis Center 820 W Jackson Blvd Chicago IL 60607 60411 Renal Dialysis 02/01/2014 CHICAGO HEIGHTS DIALYSIS 177 B JOE ORR RD CHICAGO HEIGHTS IL 1733 6308514812 60120 Renal Dialysis 02/01/2014 COBBLESTONE DIALYSIS 836 DUNDEE AVE STE A ELGIN IL 3068 8478889386 46312 Renal Dialysis 02/01/2014 COMPREHENSIVE RENAL CARE E CHGO 4320 FIR ST SUITE 404 EAST CHICAGO IN 3052 2193971199 46320 Renal Dialysis 02/01/2014 COMPREHENSIVE RENAL CARE HAMMOND 222 DOUGLAS ST HAMMOND IN 1960 2199321199 46408 Renal Dialysis 02/01/2014 CRC GARY 4802 BROADWAY GARY IN 4509 2198871199 46321 Renal Dialysis 02/01/2014 CRC MUNSTER 9100 CALUMET AVE Munster IN 1737 2198361299 60178 Renal Dialysis 02/01/2014 CRIMSON RIDGE HOME TRAINING 2540 HAUSER ROSS DR STE 200 SYCAMORE IL 3171 8157483508 60014 Renal Dialysis 02/01/2014 CRYSTAL SPRINGS DIALYSIS 720 COG CIR CRYSTAL LAKE IL 7301 8154594945 Renal Dialysis 01/01/2013 DIALYSIS CENTER OF AMERICA 4861-73 CAL SAG RD CRESTWOOD IL 60445 7083851400 60462 Renal Dialysis 01/01/2013 DIALYSIS CENTER OF AMERICA 9160 W 159TH ST ORLAND PARK IL 5648 7084032790 60645 Renal Dialysis 01/01/2013 DIALYSIS CENTER OF AMERICA 2277 W HOWARD ST CHICAGO IL 1922 7732627147 DIALYSIS CENTER OF AMERICA DBA DCA Renal Dialysis 01/01/2013 GARFIELD 5401 S Wentworth Ave, Suite 18 Chicago IL 60609 606096300 Renal Dialysis 01/01/2013 Downers Grove Dialysis Center 3825 Highland Ave, Suite 102 Downers Grove IL 60515 Renal Dialysis 02/01/2014 DSI RENAL ARLINGTON HEIGHTS 17 W GOLF RD ARLINGTON HTS IL 60005 8474372188 60089 Renal Dialysis 02/01/2014 DSI RENAL BUFFALO GROVE 1291 W DUNDEE RD BUFFALO GROVE IL 4009 8472535400

Rev. 7-2014

22 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 3053 3065 W 159TH ST SUITE Renal Dialysis 02/01/2014 DSI RENAL MARKHAM 1100 MARKHAM IL 60426 7083333516 60193 Renal Dialysis 02/01/2014 DSI RENAL SCHAUMBURG 1156 S ROSELLE RD SCHAUMBURG IL 4072 8475244310 60085 Renal Dialysis 02/01/2014 DSI RENAL WAUKEGAN 1616 GRAND AVENUE C WAUKEGAN IL 3676 8476625111 ARLINGTON 60005 Renal Dialysis 02/01/2014 DSI SCHAUMBURG HOME RENAL CENTER 17 W GOLF RD HEIGHTS IL 3905 8474372188 60085 Renal Dialysis 02/01/2014 DSI WAUKEGAN HOME RENAL CENTER 1616 GRAND AVE SUITE F WAUKEGAN IL 3600 8473609621

Renal Dialysis 01/01/2013 Elk Grove Dialysis Center 901 Biesterfield Rd, Suite 400 Elk Grove Village IL 60007

Renal Dialysis 01/01/2013 Elk Grove Home Dialysis Center 901 Biesterfield Rd, Suite 401 Elk Grove Village IL 60007 60609 Renal Dialysis 02/01/2014 EMERALD KIDNEY CENTER 710 W 43RD ST CHICAGO IL 3435 7738435668 60202 Renal Dialysis 02/01/2014 EVANSTON RENAL CENTER 1922 DEMPSTER ST EVANSTON IL 1016 8478695336

Renal Dialysis 01/01/2013 FMC Dialysis Services of Alsip 12250 S Cicero Ave, Suite 105 Alsip IL 60803

Renal Dialysis 01/01/2013 FMC Dialysis Services of Congress Parkway 3410 W Van Buren St Chicago IL 60624 Renal Dialysis 01/01/2013 FMC Dialysis Services of Willowbrook 6300 Kingery Hwy, Suite 408 Willowbrook IL 60527 60126 6308350 Renal Dialysis 01/01/2013 FMC DUPAGE HOME DIALYSIS 242 N YORK RD ELMHURST IL 2701 6308325276 276 Renal Dialysis 01/01/2013 FMC Glendale Heights Dialysis Center 520 E North Ave Glendale Heights IL 60139 Renal Dialysis 01/01/2013 FMC Hoffman Estates 3150 W Higgins Rd, Suite 190 Hoffman Estates IL 60195 Renal Dialysis 01/01/2013 08/31/2013 FMCNA Dialysis Services of Burbank 4811 W 77th St Burbank IL 60459 Renal Dialysis 01/01/2013 Freesenius Medical Care Oak Park 733 Madison St Oak Park IL 60302

Renal Dialysis 01/01/2013 Fresenius Dialysis Services of Polk Street 557 W Polk St Chicago IL 60607

Renal Dialysis 01/01/2013 Fresenius Medical Care Blue Island 12200 Western Ave, Suite 120 Blue Island IL 60406

Renal Dialysis 01/01/2013 Fresenius Medical Care Bolingbrook 329 Remington Blvd. Suite 110 Bolingbrook IL 60440 7737232 Renal Dialysis 01/01/2013 FRESENIUS MEDICAL CARE CHATHAM 8710 S HOLLAND RD CHICAGO IL 60620 7737232536 541

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23 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Fresenius Medical Care Chicago Westside Renal Dialysis 01/01/2013 Dialysis 1340 S Damen Ave. Chicago IL 60608 60804 Renal Dialysis 03/01/2013 FRESENIUS MEDICAL CARE CICERO LLC 3000 S CICERO AVE CICERO IL 3638 7086527089 Renal Dialysis 01/01/2013 Fresenius Medical Care Deerfield 405 Lake Cook Rd, Ste A13 Deerfield IL 60015 Fresenius Medical Care DuPage Home Renal Dialysis 01/01/2013 Dialysis 501 W Lake St. Suite 201 Elmhurst IL 60126 60123- Renal Dialysis 01/01/2013 Fresenius Medical Care Elgin 2130 Point Blvd Elgin IL 9215 60432 8157268 Renal Dialysis 01/01/2013 FRESENIUS MEDICAL CARE JOLIET 721 E JACKSON ST JOLIET IL 2560 8157268619 856 Fresenius Medical Care Joliet Home Dialysis Renal Dialysis 01/01/2013 Network 95 129th Infantry Dr Joliet IL 60435 Renal Dialysis 01/01/2013 Fresenius Medical Care Kewanee 230 W South St. Kewanee IL 61443 60148- Renal Dialysis 01/01/2013 Fresenius Medical Care Lombard 1940 Springer Dr Lombard IL 6419 6306930394 Fresenius Medical Care Lombard Home Renal Dialysis 01/01/2013 Therapies 1960 Springer Lombard IL 60148 Renal Dialysis 01/01/2013 Fresenius Medical Care Macomb 523 E Grant St Macomb IL 61455 Renal Dialysis 01/01/2013 Fresenius Medical Care Midway 6201 W 63rd St Chicago IL 60638 Renal Dialysis 01/01/2013 Fresenius Medical Care Mokena 8910 W 192nd St Mokena IL 60448 Renal Dialysis 01/01/2013 Fresenius Medical Care Mundelein 1402 Townline Rd Mundelein IL 60060 8479493904

Renal Dialysis 01/01/2013 Fresenius Medical Care Naperville North 516 W 5th Avenue Naperville IL 60563 6307539295 Renal Dialysis 01/01/2013 Fresenius Medical Care Niles 9371 Milwaukee Ave Niles IL 60714 Renal Dialysis 01/01/2013 Fresenius Medical Care North Avenue 911 West North Avenue Melrose Park IL 60160 Renal Dialysis 01/01/2013 Fresenius Medical Care Northcenter 2620 West Addison Chicago IL 60618 Renal Dialysis 01/01/2013 Fresenius Medical Care of Antioch 311 Depot St Antioch IL 60002

Renal Dialysis 01/01/2013 Fresenius Medical Care of Lakeview 4008 N Broadway, Suite 1200 Chicago IL 60613 7732483105 Renal Dialysis 01/01/2013 Fresenius Medical Care of McHenry 4312 W Elm St McHenry IL 60050

Renal Dialysis 01/01/2013 Fresenius Medical Care of Westchester 2400 Wolf Rd, Suite 101A Westchester IL 60154 Fresenius Medical Care of Westchester Renal Dialysis 01/01/2013 Home 2400 Wolf Rd, Suite 101 B Westchester IL 60154 Renal Dialysis 01/01/2013 Fresenius Medical Care Oswego 1051 Station Dr Oswego IL 60543 Renal Dialysis 01/01/2013 Fresenius Medical Care Ottawa 1601 Mercury Cir, Suite 3 Ottawa IL 61350 8154342125 Renal Dialysis 01/01/2013 Fresenius Medical Care Palatine 691 E Dundee Rd Palatine IL 60074

Rev. 7-2014

24 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Renal Dialysis 01/01/2013 Fresenius Medical Care Plainfield 2320 Michas Dr Plainfield IL 60585 Renal Dialysis 01/01/2013 Fresenius Medical Care Prairie 1717 S Wabash Ave. 2nd Flr Chicago IL 60616 Renal Dialysis 01/01/2013 Fresenius Medical Care River Forest 103 Forest Ave River Forest IL 60305 Renal Dialysis 01/01/2013 Fresenius Medical Care Roseland 132 W 111th St Chicago IL 60628 Fresenius Medical Care Ross Dialysis Renal Dialysis 01/01/2013 Englewood 6333 S Green St Chicago IL 60621 60617 Renal Dialysis 03/01/2013 FRESENIUS MEDICAL CARE S DEERING 10559 S TORRENCE AVE CHICAGO IL 6154 7737687100 Renal Dialysis 01/01/2013 Fresenius Medical Care Sandwich 1310 N Main St Suite 105 Sandwich IL 60548 Renal Dialysis 01/01/2013 Fresenius Medical Care Steger 219 E 34th St Steger IL 60475 Renal Dialysis 01/01/2013 Fresenius Medical Care Streator 2356 N Bloomington St Streator IL 61364 Renal Dialysis 01/01/2013 Fresenius Medical Care Uptown 4700 N Marine Dr Suite 200 Chicago IL 60640 60085- Renal Dialysis 01/01/2013 Fresenius Medical Care Waukegan Harbor 110 N West St Waukegan IL 4330 60510- Renal Dialysis 01/01/2013 Fresenius Medical Care West Batavia 2580 W Fabyan Pkwy Batavia IL 1572 Renal Dialysis 01/01/2013 Fresenius Medical Care West Chicago 1859 Neltnor Blvd West Chicago IL 60185 60642- Renal Dialysis 01/01/2013 Fresenius Medical Care West Willow 1444 W Willow St Chicago IL 1524

Renal Dialysis 01/01/2013 Fresenius Medical Services of Dupage West 450 E Roosevelt Rd West Chicago IL 60185 Renal Dialysis 01/01/2013 Fresenius of Lake Bluff 101 Waukegan Rd, Suite 700 Lake Bluff IL 60044 Renal Dialysis 01/01/2013 Glenview Dialysis Center 4248 Commercial Way Glenview IL 60025 60619 Renal Dialysis 02/01/2014 GRAND CROSSING DIALYSIS 7319 S COTTAGE GROVE AVE CHICAGO IL 1909 7737833491 Renal Dialysis 01/01/2013 Greenwood Dialysis Center 1111 E 87th St, Suite 700 Chicago IL 60619 60429 Renal Dialysis 02/01/2014 HAZEL CREST RENAL CENTER 3470 W 183RD ST HAZEL CREST IL 2428 7087993101 Renal Dialysis 01/01/2013 Jackson Park Dialysis Center 7531 S Stony Island Chicago IL 60649 581 WILLIAM R LATHAM SR DR 60914 Renal Dialysis 02/01/2014 KANKAKEE COUNTY DIALYSIS STE 104 BOURBONNAIS IL 2439 8159363088 5590 N CUMBERLAND AVE STE 60656 Renal Dialysis 02/01/2014 KENNEDY HOME DIALYSIS 515 CHICAGO IL 1421 7736318296 4259 S COTTAGE GROVE AVE 60653 Renal Dialysis 02/01/2014 KENWOOD DIALYSIS STE 100 CHICAGO IL 2929 7733639052 60061 Renal Dialysis 02/01/2014 LAKE COUNTY DIALYSIS SERVICES 565 LAKEVIEW PKWY STE 176 VERNON HILLS IL 1857 8479180592

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25 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 60046 Renal Dialysis 02/01/2014 LAKEVILLA DIALYSIS 37809 N IL RTE 59 LAKE VILLA IL 7332 8472454872 60657 Renal Dialysis 02/01/2014 LINCOLN PARK DIALYSIS 3157 N LINCOLN AVE CHICAGO IL 3111 7733480101 60634 Renal Dialysis 02/01/2014 LINCOLN PARK P D 7009 W BELMONT CHICAGO IL 4533 7736377303 60608 Renal Dialysis 02/01/2014 LITTLE VILLAGE DIALYSIS 2335 W CERMAK RD CHICAGO IL 3811 7735232939 60441 Renal Dialysis 02/01/2014 LOCKPORT HOME DIALYSIS 16626 W 159TH ST STE 703 LOCKPORT IL 8019 8158382918 60618 Renal Dialysis 02/01/2014 LOGAN SQUARE DIALYSIS 2838 N KIMBALL AVE CHICAGO IL 7524 7733423728 60607 Renal Dialysis 02/01/2014 LOOP RENAL CENTER 1101 S CANAL CHICAGO IL 4901 3123419472 46410 Renal Dialysis 02/01/2014 MERRILLVILLE DIALYSIS 9223 TAFT MERRILLVILLE IN 6911 2197939035 60634 Renal Dialysis 02/01/2014 MONTCLARE DIALYSIS CENTER 7009 BELMONT AVE CHICAGO IL 4533 7738896051 60655 Renal Dialysis 02/01/2014 MT GREENWOOD DIALYSIS 3401 W 111TH ST CHICAGO IL 3329 7734450558 Renal Dialysis 01/01/2013 Naperville Dialysis Center 100 Spalding Dr, Suite 108 Naperville IL 60540 Renal Dialysis 01/01/2013 NeoMedica Bridgeport 825 W 35th St Chicago IL 60609 Renal Dialysis 01/01/2013 NeoMedica Cumberland 4701 N Cumberland Ave Norridge IL 60706 Renal Dialysis 01/01/2013 NEOMEDICA EVERGREEN PARK 9730 S Western Ave Evergreen Park IL 60805 Renal Dialysis 01/01/2013 NeoMedica Gurnee 101 S Greenleaf St.Suite B Gurnee IL 60031 Renal Dialysis 01/01/2013 NeoMedica Hazelcrest 17524 Carriage Way Hazel Crest IL 60429 Renal Dialysis 01/01/2013 NeoMedica Marquette Park 2534 W 69th St Chicago IL 60629 Renal Dialysis 01/01/2013 NeoMedica Melrose Park 1111 Superior St, Suite 204 Melrose Park IL 60160 Renal Dialysis 01/01/2013 08/31/2013 Neomedica Munster 314 Ridge Rd Munster IN 46321 (317) 784-1428 Renal Dialysis 01/01/2013 NeoMedica North 4800 N Kilpatrick Chicago IL 60630 Renal Dialysis 01/01/2013 NeoMedica Rolling Meadows 4180 Winnetka Ave Rolling Meadows IL 60008 Renal Dialysis 01/01/2013 NeoMedica Roundlake 401 Nippersink Round Lake IL 60073 Renal Dialysis 01/01/2013 NeoMedica South 9200 S Chicago Chicago IL 60617 Renal Dialysis 01/01/2013 NeoMedica South Holland 17225 S Paxton Ave. South Holland IL 60473 Renal Dialysis 01/01/2013 NeoMedica South Shore 2420 E 79th St Chicago IL 60649 4557 B WEST LINCOLN 60443 Renal Dialysis 02/01/2014 OLYMPIA FIELDS DIALYSIS CNTR HIGHWAY MATTESON IL 0000 7085031112

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26 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 60462 Renal Dialysis 02/01/2014 PALOS PARK DIALYSIS 13155 S LAGRANGE RD ORLAND PARK IL 1162 7089230928

Renal Dialysis 01/01/2013 RCG Berwyn (formerly Riverside) 2601 South Harlem Ave, 1st Flr Berwyn IL 60402 Renal Dialysis 01/01/2013 RCG Central Illinois-Bloomington 1505 Eastland Dr Bloomington IL 61701

Renal Dialysis 01/01/2013 RCG Central Illinois-Bloomington CAPD 1404 Eastland Dr, Suite 103 Bloomington IL 61701 Renal Dialysis 01/01/2013 RCG Central Illinois-Canton 210 W Walnut Canton IL 61520 Renal Dialysis 01/01/2013 RCG Central Illinois-Decatur 1830 S 44th St Decatur IL 62521 Renal Dialysis 01/01/2013 RCG Central Illinois-Decatur (Home) 302 W Hay St, Suite 207 Decatur IL 62526 Renal Dialysis 01/01/2013 RCG Central Illinois-East Peoria 3300 N Main St East Peoria IL 61611 60450- Renal Dialysis 01/01/2013 RCG Central Illinois-Morris 1401 Lakewood Dr, Suite B Morris IL 1247 Renal Dialysis 01/01/2013 RCG Central Illinois-Pekin 600 S 13th St, 3rd Flr Pekin IL 61554 Renal Dialysis 01/01/2013 RCG Central Illinois-Peoria Downtown 410 RB Garrett Ave Peoria IL 61605 Renal Dialysis 01/01/2013 RCG Central Illinois-Peoria North 10405 N Juliet Ct Peoria IL 61615 Renal Dialysis 01/01/2013 RCG Central Illinois-Pontiac 804 W Madison St Pontiac IL 61764 Renal Dialysis 01/01/2013 RCG Central Illinois-Spring Valley 12 Wolfer Industrial Dr Spring Valley IL 61362 Renal Dialysis 01/01/2013 RCG Evanston 2953 Central St, Flr 1 Evanston IL 60201 Renal Dialysis 01/01/2013 RCG Merrionette Park 11630 S Kedzie Ave Merrionette Park IL 60803 710 N Fairbanks Ct Wesley Renal Dialysis 01/01/2013 RCG Northwestern Pavilion, 4th Flr Chicago IL 60611 Renal Dialysis 01/01/2013 RCG Orland Park 9160 W 159th St Orland Park IL 60462 60077 8475811 Renal Dialysis 01/01/2013 RCG SKOKIE 9801 WOODS DRIVE SKOKIE IL 1074 8475811620 659 Renal Dialysis 01/01/2013 RCG Villa Park 200 E North Ave Villa Park IL 60181 Renal Dialysis 01/01/2013 Renal Care Group South Suburban 2609 W Lincoln Hwy Olympia Fields IL 60461 60451 Renal Dialysis 02/01/2014 RENAL CENTER NEW LENOX 1890 SILVER CROSS BLVD NEW LENOX IL 9524 8157407144 60435 Renal Dialysis 02/01/2014 RENAL CENTER WEST JOLIET 1051 ESSINGTON RD JOLIET IL 2801 8157299240 60473 Renal Dialysis 02/01/2014 SOUTH HOLLAND RENAL CENTER 16136 S PARK AVE SOUTH HOLLAND IL 1511 7083310200 Renal Dialysis 01/01/2013 Southside Dialysis Center 3134 W 76th St Chicago IL 60652 60453 Renal Dialysis 02/01/2014 STONY CREEK DIALYSIS 9115 S CICERO AVE OAK LAWN IL 1895 7084230300 60617 Renal Dialysis 02/01/2014 STONY ISLAND DIALYSIS 8725 S STONY ISLAND AVE CHICAGO IL 2709 7732217320

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27 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 60178 Renal Dialysis 02/01/2014 SYCAMORE DIALYSIS 2200 GATEWAY DR SYCAMORE IL 3113 8157580205 60614 Renal Dialysis 02/01/2014 TRC CHILDRENS DIALYSIS CNTR 2611 N HALSTED CHICAGO IL 2301 7735492010 60629 Renal Dialysis 02/01/2014 WEST LAWN DIALYSIS 7000 S PULASKI RD CHICAGO IL 5842 7732845324 Renal Dialysis 01/01/2013 West Metro Dialysis Center 1044 N Mozart St Chicago IL 60622 Renal Dialysis 01/01/2013 West Suburban Dialysis Center 518 N Austin 5th Flr Oak Park IL 60302 60609 Renal Dialysis 02/01/2014 WOODLAWN DIALYSIS 5060 S STATE ST CHICAGO IL 5328 7739242149 60517 Renal Dialysis 02/01/2014 WOODRIDGE HOME DIALYSIS 7425 JANES AVE WOODRIDGE IL 2356 6309680081

A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

Rev. 7-2014

28 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Alden Des Plaines Rehabilitation and Health 60016- Skilled Nursing 01/01/2013 Care Center, Inc. 1221 East Golf Road Des Plaines Il 1213 (847) 768-1300 A 11/02/12 60010- Skilled Nursing 01/01/2013 Alden Estates of Barrington, Inc. 1420 South Barrington Road Barrington IL 5206 (847) 382-6664 A 11/02/12

Skilled Nursing 01/01/2013 Alden Estates of Shorewood 750 W Black Rd Shorewood IL 60404 (815) 230-8700 A 11/01/12

Skilled Nursing 01/01/2013 ALDEN ESTATES OF SKOKIE INC 4660 Old Orchard Road Skokie IL 60076 (847) 676-4800 A 11/02/12 60426- Skilled Nursing 01/01/2013 ALDEN HEATHER REHAB HLTHCARE CNTR 15600 Honore Harvey IL 4102 (708) 333-9550 A 11/02/12 Alden Lakeland Rehabilitation and Health 60640- Skilled Nursing 01/01/2013 Care Center, Inc. 820 West Lawrence Avenue Chicago IL 4213 (773) 769-2570 A 11/02/12 Alden Lincoln Park Rehabilitation and 60657- Skilled Nursing 01/01/2013 Health Care Center, Inc. 504 West Wellington Avenue Chicago IL 5421 (773) 281-6200 A 11/01/12 Alden Naperville Rehabilitation and Health 60565- Skilled Nursing 01/01/2013 Care Center, Inc. 1525 Oxford Lane Naperville IL 1511 (630) 983-0300 A 11/01/12 Alden North Shore Rehabilitation and Skilled Nursing 01/01/2013 Health Care Center, Inc. 5050 West Touhy Avenue Skokie IL 60077 (847) 679-6100 A 11/01/12 Alden Northmoor Rehabilitation and Health 60631- Skilled Nursing 01/01/2013 Care Center, Inc. 5831 North Northwest Highway Chicago IL 2642 (773) 775-8080 A 11/01/12 60201- Skilled Nursing 01/01/2013 ALDEN NURSING CENTER EVANSTON 2520 Gross Point Road Evanston IL 4929 (847) 328-6000 A 11/02/12 60504- Skilled Nursing 01/01/2013 Alden of Waterford, L.L.C. 2021 Randi Drive Aurora IL 4758 (630) 851-7266 A 11/01/12 Alden Orland Park Rehabilitation and Health 60467- Skilled Nursing 01/01/2013 Care Center, Inc. 16450 South 97th Avenue Orland Park IL 5587 (708) 403-6500 A 11/01/12 Alden Poplar Creek Rehabilitation and 60194- Skilled Nursing 01/01/2013 Health Care Center, Inc. 1545 Barrington Road Hoffman Estates IL 1018 (847) 884-0011 A 11/01/12 Alden Princeton Rehabilitation and Health 60621- Skilled Nursing 01/01/2013 Care Center, Inc. 255 West 69th Street Chicago IL 3767 (773) 224-5900 A 11/01/12 Alden Town Manor Rehabilitation and 60804- Skilled Nursing 01/01/2013 Health Care Center, Inc. 6120 West Ogden Cicero IL 3743 (708) 863-0500 A 11/01/12 Alden Valley Ridge Rehabilitation and 60108- Skilled Nursing 01/01/2013 Health Care Center, Inc. 275 East Army Trail Road Bloomingdale IL 2135 (630) 893-9616 A 11/01/12 Alden Wentworth Rehabilitation and 60621- Skilled Nursing 01/01/2013 11/30/2013 Healthcare Center, Inc. 201 West 69th Street Chicago IL 3719 (773) 487-1200 A 11/01/12

Skilled Nursing 01/01/2013 Dupage Convalescent Center 400 N Country Farm Rd Wheaton IL 60187 (630) 665-6400

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29 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Elmcare/Elmhurst Mem. Hosp. - Skilled Nursing 01/01/2013 Transitional Care Ct. 200 Berteau Elmhurst IL 60126 (630) 833-8200

Skilled Nursing 01/01/2013 Elmhurst Extended Care Center 200 E. Lake Street Elmhurst IL 60126 (630) 834-4337

Skilled Nursing 01/01/2013 Lexington Health Care Center Bloomingdale 165 S Bloomingdale Rd Bloomingdale IL 60108 (630) 980-8700

Skilled Nursing 01/01/2013 Lexington Health Care Center Chicago Ridge 10300 Southwest Highway Chicago Ridge IL 60415 (630) 458-4700

Skilled Nursing 01/01/2013 Lexington Health Care Center Elmhurst 420 W Butterfield Rd Elmhurst IL 60126 (630) 832-2300

Skilled Nursing 01/01/2013 Lexington Health Care Center LaGrange 4735 Willow Springs Rd LaGrange IL 60525 (708) 352-6900 60047- Skilled Nursing 01/01/2013 Lexington Health Care Center Lake Zurich 900 S Rand Rd Lake Zurich Il 2450 (847) 726-1200

Skilled Nursing 01/01/2013 Lexington Health Care Center Lombard 2100 S Finley Rd Lombard IL 60148 (630) 495-4000

Skilled Nursing 01/01/2013 Lexington Health Care Center Orland Park 14601 S John Humphrey Dr Orland Park IL 60462 (708) 349-8300

Skilled Nursing 01/01/2013 Lexington Health Care Center Schaumburg 675 S Roselle Rd Schaumburg IL 60193 (847) 352-5500

Skilled Nursing 01/01/2013 Lexington Health Care Center Streamwood 815 E Irving Park Rd Streamwood IL 60107 (630) 837-5300

Skilled Nursing 01/01/2013 Lexington Health Care Center Wheeling 730 W Hintz Rd Wheeling IL 60090 (847) 537-7474

Skilled Nursing 01/01/2013 Manor Care at Arlington Heights 715 W. Central Road Arlington Hgts IL 60005 (847) 392-2020

Skilled Nursing 01/01/2013 Manor Care at Naperville 200 Martin Ave. Naperville IL 60540 (630) 355-4111

Skilled Nursing 01/01/2013 Manor Care at South Holland 2145 E. 170th Street South Holland IL 60473 (708) 895-3255

Skilled Nursing 01/01/2013 Manor Care Health Serv. Oak Lawn East 9401 S. Kostner Ave. Oak Lawn IL 60453 (708) 423-7882

Skilled Nursing 01/01/2013 Manor Care Health Services - Elk Grove 1920 Nerge Road Elk Grove Village IL 60007 (847) 301-0550

Skilled Nursing 01/01/2013 Manor Care Health Services - Hinsdale 600 West Ogden Ave. Hinsdale IL 60521 (630) 325-9630

Skilled Nursing 01/01/2013 Manor Care Health Services - Westmont 512 E. Ogden Ave. Westmont IL 60559 (630) 323-4400

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30 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date 60123- Skilled Nursing 01/01/2013 Manor Care Health Services Elgin 180 S. State St. Elgin IL 6429 (847) 742-3310 MANOR CARE HLTHCARE SRVS 60430 Skilled Nursing 01/01/2013 HOMEWOOD 940 MAPLE RD HOMEWOOD IL 2061 7087990244

Skilled Nursing 01/01/2013 Manor Care Health Services Northbrook 3300 Milwaukee Avenue Northbrook IL 60062 (847) 795-9799 60048- Skilled Nursing 01/01/2013 Manor Health Services Libertyville 1500 S Milwaukee Ave. Libertyville IL 3723 (847) 816-3200 60091 Skilled Nursing 01/01/2013 MANOR CARE HEALTH SRVCS WILMETTE 432 POPLAR DR WILMETTE IL 2731 8472565000 60463 Skilled Nursing 01/01/2014 MARIANJOY PROVIDENCE HEALTHCARE 13259 S CENTRAL AVE PALOS HEIGHTS IL 2601 7082396060 60515 Skilled Nursing 01/01/2014 MARIANJOY PROVIDENCE HEALTHCARE 3450 SARATOGA AVE DOWNERS GROVE IL 1141 6309699360 60187 Skilled Nursing 05/01/2013 MARIANJOY REHABILITATION HOSP 26 W 171 ROOSEVELT RD WHEATON IL 6078 6309098000

Skilled Nursing 01/01/2013 Our Lady of the Resurrection 5645 W. Addison Chicago IL 60634 (773) 282-7000 60631- Skilled Nursing 01/01/2013 Resurrection Life Center 7370 W. Talcott Ave Chicago IL 3751 (773) 594-7400

Skilled Nursing 01/01/2013 Resurrection Nursing and Rehab 1001 N. Greenwood Avenue Park Ridge IL 60068 (847) 692-5600 60431- Skilled Nursing 01/01/2013 Rosewood Care Center of Joliet 3401 Hennepin Drive Joliet IL 1080 (815) 436-5900

Skilled Nursing 01/01/2013 Rosewood Care Center of Northbrook 4101 Lake Cook Road Northbrook IL 60062 (847) 562-1770 61108- Skilled Nursing 01/01/2013 Rosewood Care Center Rockford 1660 S Mulford Road Rockford IL 6760 (815) 397-8700

Skilled Nursing 01/01/2013 Salem Village Nursing and Rehab 1314 Rowell Avenue Joliet IL 60433 (815) 727-5451 60608- Skilled Nursing 01/01/2013 Schwab Rehabilitation Center 1401 S. California Ave. Chicago IL 1858 (773) 522-2010

Skilled Nursing 01/01/2013 Sherman West Court 1950 Larkin Ave Elgin IL 60123 (847) 742-7070

Skilled Nursing 01/01/2013 South Suburban Hosp. SNF 17800 S. Kedzie Ave. Hazel Crest Il 60429 (708) 799-8000

Skilled Nursing 01/01/2013 St. Francis Extended Care Facility 500 Asbury Ave Evanston IL 60202 (847) 869-3600

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31 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date

Skilled Nursing 01/01/2013 St. Joseph Hospital, SNF 2900 North Lake Shore Dr. Chicago IL 60657 (773) 975-3000 60622- Skilled Nursing 01/01/2013 St. Mary and Elizabrth Medical Center 2233 W. Division Chicago IL 8151 (312) 770-2000 60622- Skilled Nursing 01/01/2013 St. Mary and Elizabrth Medical Center 2233 W. Division Chicago IL 8151 (312) 770-2000

Skilled Nursing 01/01/2013 Swedish Covenant Hosp. ECF 5145 North California Ave. Chicago IL 60625 (773) 878-8200

Skilled Nursing 01/01/2013 Tabor Hills HealthCare Facility, Inc 1347 Crystal Ave Naperville IL 60563 (630) 548-9540 A 11/02/12

Skilled Nursing 01/01/2013 VHS West Suburban Medical Center SNF Erie at Austin Oak Park IL 60302 (708) 363-6200

Skilled Nursing 01/01/2013 VHS Westlake Hospital Inc 1225 Superior Street Melrose Park IL 60160 (708) 681-3000

Skilled Nursing 01/01/2013 West Suburban Hospital Erie at Austin Oak Park IL 60302 (708) 363-6200 60805 Skilled Nursing 02/01/2014 EVERGREEN LIVING AND REHAB CTR 10124 S KEDZIE EVERGREEN PARK IL 3738 7089077000 CP 01/31/2014 60016 Skilled Nursing 01/01/2013 PRESENCE BALLARD NURSING CTR 9300 W BALLARD RD DES PLAINES IL 4904 7084786382 60714 Skilled Nursing 01/01/2013 PRESENCE ST BENEDICT NURS REHAB 6930 W TOUHY AVE NILES IL 4522 7084786382 60164 Skilled Nursing 01/01/2013 PRESENCE VILLA SCALABRINI NUR & R 480 N WOLF RD NORTHLAKE IL 1650 7084786382 60506 Skilled Nursing 01/01/2013 PROVENA MCAULEY MANOR 400 W SULLIVAN RD AURORA IL 1452 6308593700 60174 Skilled Nursing 01/01/2013 PROVENA PINE VIEW CARE CENTER 611 ALLEN LN ST CHARLES IL 1355 6303772211 60435 Skilled Nursing 01/01/2013 PROVENA VILLA FRANCISCAN 210 N SPRINGFIELD AVE JOLIET IL 6589 8157253400 60610 Skilled Nursing 02/01/2014 WARREN BARR LIVING AND REHAB 66 W OAK ST CHICAGO IL 7325 3127055100

A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate

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32 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

Rev. 7-2014

33 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Appendix D MEDICARE ADVANTAGE CONTRACTED PROVIDER NETWORK

Change Provider Type Effective Date Cancel Date Provider Name Address City State Zip Telephone Code Change Date Substance Use Disorder 01/01/2013 PRESENCE BEHAVIORAL HEALTH 2001 Butterfield Rd. #320 Downers Grove IL 60515 (847) 493-3600 A 11/26/12 Substance Use Proviso Family Services dba RBH - Addiction Disorder 01/01/2013 Services 8 S. Michigan Ave, #2110 Chicago IL 60603 (847) 493-3700 A 11/26/12 Substance Use Proviso Family Services dba RBH - Addiction Disorder 01/01/2013 Services 71 N. Waukegan Rd, #900 Lake Bluff IL 60044 (847) 493-3575 A 11/26/12 Substance Use Proviso Family Services dba RBH - Addiction Disorder 01/01/2013 Services 11824 Southwest Hwy., #230 Palos Heights IL 60463 (847) 493-3650 A 11/26/12 Substance Use Proviso Family Services dba RBH - Addiction 2913 N. Commonwealth Ave, Disorder 01/01/2013 Services 6th fl Chicago IL 60657 (847) 493-3500 A 11/26/12 Substance Use Disorder - IP 01/01/2013 Saint Joseph Behavioral Health 2900 N Lake Shore Dr. Chicago IL 60657 (773) 665-3371 A 11/26/12 Substance Use Disorder - OP 01/01/2013 Saint Joseph Behavioral Health 2900 N Lake Shore Dr. Chicago IL 60657 (773) 665-3371 A 11/26/12

A: New C: Cancel N: Prov. Name P: Prov. Number R: Reinstate AC: Accreditation Cancel AD: Address CP: Cancel prov # changed PN: Name and Number TE: Telephone Number TI: Transfer into a class TO: Transfer out of a class

Rev. 7-2014

34 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association