summary of benefits - ehealthinsurance of benefits for anthem medicare preferred ... you may be able...

Summary of Benefitsfor Anthem Medicare Preferred Standard (PPO)and Anthem Medicare Preferred Premier (PPO)

Available in Albemarle, Charles City, Charlottesville City, Chesapeake City,Chesterfield, Colonial Heights City, Dinwiddie, Fluvanna, Gloucester,Goochland, Hampton City, Hanover, Henrico, Hopewell City, James City,King and Queen, Lancaster, Louisa, Mathews, Middlesex, Montgomery, NewKent, Newport News City, Norfolk City, Northampton, Northumberland,Orange, Petersburg City, Poquoson City, Portsmouth City, Powhatan, PrinceGeorge, Pulaski, Richmond, Richmond City, Roanoke, Roanoke City, SalemCity, Suffolk City, Virginia Beach City, Williamsburg City, and York Countiesin Virginia

This plan is a PPO plan with a Medicare contract. Anthem Health Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax,the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield is anindependent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademarkof Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registeredmarks of the Blue Cross and Blue Shield Association.

Y0071_12_12911_T_011 CMS Approved 09/15/2011 23459MUSENMUB_011H4909 001_004 VA LPPO

Section I:

Introduction to the Summary of BenefitsThank you for your interest in Anthem Medicare Preferred Standard (PPO) and Anthem Medicare Preferred Premier(PPO). Our plans are offered by Anthem Health Plans of Virginia, Inc., a Medicare Advantage Preferred ProviderOrganization (PPO). This Summary of Benefits tells you some features of our plan. It doesn't list every service thatwe cover or list every limitation or exclusion. To get a complete list of our benefits, please call Anthem MedicarePreferred Standard (PPO) and Anthem Medicare Preferred Premier (PPO) and ask for the "Evidence of Coverage".

You Have Choices in Your Health CareAs a Medicare beneficiary, you can choose from differentMedicare options. One option is the Original(fee-for-service) Medicare Plan. Another option is aMedicare health plan, like Anthem Medicare PreferredStandard (PPO) and Anthem Medicare Preferred Premier(PPO). You may have other options too. You make thechoice. No matter what you decide, you are still in theMedicare Program.

You may be able to join or leave a plan only at certaintimes. Please call Anthem Medicare Preferred Standard(PPO) and Anthem Medicare Preferred Premier (PPO)at the number listed at the end of this introduction or1-800-MEDICARE (1-800-633-4227) for moreinformation. TTY/TDD users should call1-877-486-2048. You can call this number 24 hours aday, 7 days a week.

How Can I Compare My Options?You can compare Anthem Medicare Preferred Standard(PPO) and Anthem Medicare Preferred Premier (PPO)and the Original Medicare Plan using this Summary ofBenefits. The charts in this booklet list some importanthealth benefits. For each benefit, you can see what ourplan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the OriginalMedicare Plan offers. We also offer more benefits, whichmay change from year to year.

Where Are Anthem Medicare PreferredStandard (PPO) and Anthem MedicarePreferred Premier (PPO) Available?The service area for these plans includes the followingcounties:

Albemarle, Charles City, Charlottesville City, ChesapeakeCity, Chesterfield, Colonial Heights City, Dinwiddie,Fluvanna, Gloucester, Goochland, Hampton City,Hanover, Henrico, Hopewell City, James City, King andQueen, Lancaster, Louisa, Mathews, Middlesex,Montgomery, New Kent, Newport News City, NorfolkCity, Northampton, Northumberland, Orange,Petersburg City, Poquoson City, Portsmouth City,Powhatan, Prince George, Pulaski, Richmond, RichmondCity, Roanoke, Roanoke City, Salem City, Suffolk City,Virginia Beach City, Williamsburg City, and Yorkcounties, VA.

You must live in one of these areas to join the plan.

There is more than one plan listed in this Summary ofBenefits. If you are enrolled in one plan and wish toswitch to another plan, you may do so only during certaintimes of the year. Please call Customer Service for moreinformation.

Who Is Eligible to Join AnthemMedicare Preferred Standard (PPO)and Anthem Medicare PreferredPremier (PPO)?You can join Anthem Medicare Preferred Standard (PPO)and Anthem Medicare Preferred Premier (PPO) if youare entitled to Medicare Part A and enrolled in Medicare

– Anthem Medicare Preferred Standard (PPO) and Anthem Medicare Preferred Premier (PPO)

Part B and live in the service area. However, individualswith End-Stage Renal Disease are generally not eligibleto enroll in Anthem Medicare Preferred Standard (PPO)and Anthem Medicare Preferred Premier (PPO) unlessthey are members of our organization and have been sincetheir dialysis began.

Can I Choose My Doctors?Anthem Medicare Preferred Standard (PPO) and AnthemMedicare Preferred Premier (PPO) have formed anetwork of doctors, specialists, and hospitals. You canuse any doctor who is part of our network. You may alsogo to doctors outside of our network. The healthproviders in our network can change at any time.

You can ask for a current provider directory. For anupdated list, visit us at www.anthem.com/medicare. Ourcustomer service number is listed at the end of thisintroduction.

What Happens If I Go to a Doctor Who'sNot in Your Network?You can go to doctors, specialists, or hospitals in or outof network. You may have to pay more for the servicesyou receive outside the network, and you may have tofollow special rules prior to getting services in and/or outof network. For more information, please call thecustomer service number at the end of this introduction.

Where Can I Get My Prescriptions If IJoin these plans?Anthem Medicare Preferred Standard (PPO) and AnthemMedicare Preferred Premier (PPO) have formed anetwork of pharmacies. You must use a networkpharmacy to receive plan benefits. We may not pay foryour prescriptions if you use an out-of-networkpharmacy, except in certain cases. The pharmacies in ournetwork can change at any time. You can ask for apharmacy directory or visit us at www.anthem.com/medicare. Our customer service number is listed at theend of this introduction.

Does My Plan Cover Medicare Part Bor Part D Drugs?Anthem Medicare Preferred Standard (PPO) and AnthemMedicare Preferred Premier (PPO) do cover bothMedicare Part B prescription drugs and Medicare PartD prescription drugs.

What Is a Prescription Drug Formulary?Anthem Medicare Preferred Standard (PPO) and AnthemMedicare Preferred Premier (PPO) use a formulary. Aformulary is a list of drugs covered by your plan to meetpatient needs. We may periodically add, remove, or makechanges to coverage limitations on certain drugs or changehow much you pay for a drug. If we make any formularychange that limits our members' ability to fill theirprescriptions, we will notify the affected enrollees beforethe change is made. We will send a formulary to you andyou can see our complete formulary on our Web site atwww.anthem.com/medicare.

If you are currently taking a drug that is not on ourformulary or subject to additional requirements or limits,you may be able to get a temporary supply of the drug.You can contact us to request an exception or switch toan alternative drug listed on our formulary with yourphysician's help. Call us to see if you can get a temporarysupply of the drug or for more details about our drugtransition policy.

How Can I Get Extra Help With MyPrescription Drug Plan Costs or GetExtra Help With Other Medicare Costs?You may be able to get extra help to pay for yourprescription drug premiums and costs as well as get helpwith other Medicare costs. To see if you qualify forgetting extra help, call:

* 1-800-MEDICARE (1-800-633-4227). TTY/TDDusers should call 1-877-486-2048, 24 hours a day/7 daysa week and see www.medicare.gov 'Programs for People


with Limited Income and Resources' in the publicationMedicare & You.

* The Social Security Administration at 1-800-772-1213between 7 a.m. and 7 p.m., Monday through Friday.TTY/TDD users should call 1-800-325-0778 or

* Your State Medicaid Office.

What Are My Protections in theseplans?All Medicare Advantage Plans agree to stay in theprogram for a full calendar year at a time. Plan benefitsand cost-sharing may change from calendar year tocalendar year. Each year, plans can decide whether tocontinue to participate with Medicare Advantage. A planmay continue in their entire service area (geographic areawhere the plan accepts members) or choose to continueonly in certain areas. Also, Medicare may decide to enda contract with a plan. Even if your Medicare AdvantagePlan leaves the program, you will not lose Medicarecoverage. If a plan decides not to continue for anadditional calendar year, it must send you a letter at least90 days before your coverage will end. The letter willexplain your options for Medicare coverage in your area.

As a member of Anthem Medicare Preferred Standard(PPO) and Anthem Medicare Preferred Premier (PPO),you have the right to request an organizationdetermination, which includes the right to file an appealif we deny coverage for an item or service, and the rightto file a grievance. You have the right to request anorganization determination if you want us to provide orpay for an item or service that you believe should becovered. If we deny coverage for your requested item orservice, you have the right to appeal and ask us to reviewour decision. You may ask us for an expedited (fast)coverage determination or appeal if you believe thatwaiting for a decision could seriously put your life orhealth at risk, or affect your ability to regain maximumfunction. If your doctor makes or supports the expeditedrequest, we must expedite our decision. Finally, you havethe right to file a grievance with us if you have any typeof problem with us or one of our network providers thatdoes not involve coverage for an item or service. If yourproblem involves quality of care, you also have the rightto file a grievance with the Quality Improvement

Organization (QIO) for your state. Please refer to theEvidence of Coverage (EOC) for the QIO contactinformation.

As a member of Anthem Medicare Preferred Standard(PPO) and Anthem Medicare Preferred Premier (PPO),you have the right to request a coverage determination,which includes the right to request an exception, the rightto file an appeal if we deny coverage for a prescriptiondrug, and the right to file a grievance. You have the rightto request a coverage determination if you want us tocover a Part D drug that you believe should be covered.An exception is a type of coverage determination. Youmay ask us for an exception if you believe you need adrug that is not on our list of covered drugs or believeyou should get a non-preferred drug at a lowerout-of-pocket cost. You can also ask for an exception tocost utilization rules, such as a limit on the quantity ofa drug. If you think you need an exception, you shouldcontact us before you try to fill your prescription at apharmacy. Your doctor must provide a statement tosupport your exception request. If we deny coverage foryour prescription drug(s), you have the right to appealand ask us to review our decision. Finally, you have theright to file a grievance if you have any type of problemwith us or one of our network pharmacies that does notinvolve coverage for a prescription drug. If your probleminvolves quality of care, you also have the right to file agrievance with the Quality Improvement Organization(QIO) for your state. Please refer to the Evidence ofCoverage (EOC) for the QIO contact information.

What Is a Medication TherapyManagement (MTM) Program?A Medication Therapy Management (MTM) Programis a free service we offer. You may be invited to participatein a program designed for your specific health andpharmacy needs. You may decide not to participate butit is recommended that you take full advantage of thiscovered service if you are selected. Contact AnthemMedicare Preferred Standard (PPO) and AnthemMedicare Preferred Premier (PPO) for more details.


What Types of Drugs May Be CoveredUnder Medicare Part B?Some outpatient prescription drugs may be covered underMedicare Part B. These may include, but are not limitedto, the following types of drugs. Contact AnthemMedicare Preferred Standard (PPO) and AnthemMedicare Preferred Premier (PPO) for more details.

Some Antigens: If they are prepared by a doctor andadministered by a properly instructed person (whocould be the patient) under doctor supervision.Osteoporosis Drugs: Injectable drugs for osteoporosisfor certain women with Medicare.Erythropoietin (Epoetin Alfa or Epogen®): Byinjection if you have end-stage renal disease(permanent kidney failure requiring either dialysis ortransplantation) and need this drug to treat anemia.Hemophilia Clotting Factors: Self-administeredclotting factors if you have hemophilia.Injectable Drugs: Most injectable drugs administeredincident to a physician's service.Immunosuppressive Drugs: Immunosuppressive drugtherapy for transplant patients if the transplant waspaid for by Medicare, or paid by a private insurancethat paid as a primary payer to your Medicare Part Acoverage, in a Medicare-certified facility.

Some Oral Cancer Drugs: If the same drug is availablein injectable form.Oral Anti-Nausea Drugs: If you are part of ananti-cancer chemotherapeutic regimen.Inhalation and Infusion Drugs administered throughDME.

Where Can I Find Information On PlanRatings?The Medicare program rates how well plans perform indifferent categories (for example, detecting and preventingillness, ratings from patients and customer service). Ifyou have access to the web, you may use the web toolson www.medicare.gov and select "Health and DrugPlans" then "Compare Drug and Health Plans" tocompare the Plan Ratings for Medicare plans in yourarea. You can also call us directly to obtain a copy of thePlan Ratings for these plans. Our customer servicenumber is listed below.

Please call Anthem Blue Cross and Blue Shield for more information aboutAnthem Medicare Preferred Standard (PPO) and Anthem Medicare PreferredPremier (PPO).

Prospective members should call locally forquestions related to the Medicare Advantageprogram or the Medicare Part D Prescription Drugprogram. 1-800-916-2583 (TTY/TDD 711)

Visit us at www.anthem.com/medicare or, call us:

Customer Service Hours: Sunday, Monday, Tuesday,Wednesday, Thursday, Friday, Saturday, 8:00 a.m. -8:00 p.m. Eastern

For more information about Medicare, please callMedicare at 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048. You can call24 hours a day, 7 days a week.

Current members should call toll-free for questionsrelated to the Medicare Advantage program or theMedicare Part D Prescription Drug program. 1-866-827-9866 (TTY/TDD 711)

Or, visit www.medicare.gov on the Web.


Prospective members should call toll-free forquestions related to the Medicare Advantageprogram or the Medicare Part D Prescription Drugprogram. 1-800-916-2583 (TTY/TDD 711)

This document may be available in other formats suchas Braille, large print or other alternate formats.

This document may be available in a non-Englishlanguage. For additional information, call customerservice at the phone number listed above.

Current members should call locally for questionsrelated to the Medicare Advantage program or theMedicare Part D Prescription Drug program.1-866-827-9866 (TTY/TDD 711)


If you have any questions about this plan's benefits or costs, please contact Anthem Blue Cross and Blue Shieldfor details

Section II:

Summary of BenefitsAnthem MedicarePreferred Premier(PPO)

Anthem MedicarePreferred Standard(PPO)

Original MedicareBenefit

IMPORTANT INFORMATION

General$39 monthly plan premiumin addition to your monthlyMedicare Part B premium.

General$0 monthly plan premium inaddition to your monthlyMedicare Part B premium.

In 2011 the monthly Part BPremium was $96.40 and maychange for 2012 and theannual Part B deductible

1 Premium andOther ImportantInformation

amount was $162 and maychange for 2012.

Most people will pay thestandard monthly Part B


premium in addition to theirpremium in addition to theirMA plan premium. However,MA plan premium. However,If a doctor or supplier does

not accept assignment, their some people will pay higherPart B and Part D premiums

some people will pay higherPart B and Part D premiumscosts are often higher, which

means you pay more. because of their yearly income(over $85,000 for singles,

because of their yearly income(over $85,000 for singles,


$170,000 for marriedcouples). For more

$170,000 for marriedcouples). For more

premium. However, some information about Part B andinformation about Part B andpeople will pay a higher Part D premiums based onPart D premiums based onpremium because of their income, call Medicare atincome, call Medicare atyearly income (over $85,000 1-800-MEDICARE1-800-MEDICAREfor singles, $170,000 for (1-800-633-4227). TTY users(1-800-633-4227). TTY usersmarried couples). For more should call 1-877-486-2048.should call 1-877-486-2048.information about Part B You may also call SocialYou may also call Socialpremiums based on income, Security at 1-800-772-1213.Security at 1-800-772-1213.call Medicare at TTY users should call

1-800-325-0778.TTY users should call1-800-325-0778.1-800-MEDICARE

(1-800-633-4227). TTY usersSome physicians, providersand suppliers that are out of a

Some physicians, providersand suppliers that are out of a

should call 1-877-486-2048.You may also call Social

plan's network (i.e.,plan's network (i.e.,Security at 1-800-772-1213.out-of-network) acceptout-of-network) acceptTTY users should call

1-800-325-0778. "assignment" from Medicareand will only charge up to a

"assignment" from Medicareand will only charge up to a

Medicare-approved amount.Medicare-approved amount.

– Anthem Medicare Preferred Standard (PPO) and Anthem Medicare Preferred Premier (PPO)23459MUSENMUB_011

Anthem MedicarePreferred Premier(PPO)



If you choose to see anout-of-network physician who

If you choose to see anout-of-network physician who

does NOT accept Medicare does NOT accept Medicare"assignment," your "assignment," yourcoinsurance can be based on coinsurance can be based onthe Medicare-approved the Medicare-approvedamount plus an additional amount plus an additionalamount up to a higher amount up to a higherMedicare "limiting charge." If Medicare "limiting charge." Ifyou are a member of a plan you are a member of a planthat charges a copay for that charges a copay forout-of-network physician out-of-network physicianservices, the higher Medicare services, the higher Medicare"limiting charge" does not "limiting charge" does notapply. See the publications apply. See the publicationsMedicare You or Your Medicare You or YourMedicare Benefits available on Medicare Benefits available onwww.medicare.gov for a full www.medicare.gov for a fulllisting of benefits under listing of benefits underOriginal Medicare, as well as Original Medicare, as well asfor explanations of the rules for explanations of the rulesrelated to "assignment" and related to "assignment" and"limiting charges" that applyby benefit type.

"limiting charges" that applyby benefit type.

To find out if physicians andDME suppliers accept

To find out if physicians andDME suppliers accept

assignment or participate in assignment or participate inMedicare, visit Medicare, visitwww.medicare.gov/physician www.medicare.gov/physicianor www.medicare.gov/ or www.medicare.gov/supplier. You can also call supplier. You can also call1-800-MEDICARE, or ask 1-800-MEDICARE, or askyour physician, provider, or your physician, provider, orsupplier if they acceptassignment.

supplier if they acceptassignment.

In-Network$4,500 out-of-pocket limit.All plan services included.

In-Network$3,350 out-of-pocket limit.All plan services included.





In and Out-of-Network$4,500 out-of-pocket limit.All plan services included.

In and Out-of-Network$3,350 out-of-pocket limit.All plan services included.

In-NetworkNo referral required fornetwork doctors, specialists,and hospitals.

In-NetworkNo referral required fornetwork doctors, specialists,and hospitals.

You may go to any doctor,specialist or hospital thataccepts Medicare.

2 Doctor andHospital Choice(For moreinformation, seeEmergency Care -#15 and UrgentlyNeeded Care -#16.)

In and Out-of-NetworkYou can go to doctors,specialists, and hospitals in orout of the network. It will cost

In and Out-of-NetworkYou can go to doctors,specialists, and hospitals in orout of the network. It will cost

more to get out of networkbenefits.

more to get out of networkbenefits.

Out of Service AreaPlan covers you when youtravel in the U.S.

Out of Service AreaPlan covers you when youtravel in the U.S.

SUMMARY OF BENEFITS

Inpatient Care

In-NetworkNo limit to the number ofdays covered by the plan eachhospital stay.

In-NetworkNo limit to the number ofdays covered by the plan eachhospital stay.

In 2011 the amounts for eachbenefit period were:

3 InpatientHospital Care(includesSubstance AbuseandRehabilitationServices)

Days 1 - 60: $1132deductible

For Medicare-covered hospitalstays:


Days 61 - 90: $283 perdayDays 91 - 150: $566 perlifetime reserve day

Days 1 - 7: $195 copay perday


These amounts may changefor 2012.



Call 1-800-MEDICARE(1-800-633-4227) for

$0 copay for additionalhospital days


information about lifetimereserve days.

$1,365 out-of-pocket limitevery year.

Except in an emergency, yourdoctor must tell the plan that





you are going to be admittedto the hospital.

Lifetime reserve days can onlybe used once.

Except in an emergency, yourdoctor must tell the plan thatyou are going to be admittedto the hospital.

Out-of-NetworkFor hospital stays:

A "benefit period" starts theday you go into a hospital orskilled nursing facility. It ends Out-of-Network

For hospital stays:Days 1 - 7: $205 copay perdaywhen you go for 60 days in a

row without hospital or skilled Days 1 - 7: $195 copay perday

Days 8 and beyond: $0copay per daynursing care. If you go into

the hospital after one benefit Days 8 and beyond: $0copay per dayperiod has ended, a new

benefit period begins. Youmust pay the inpatienthospital deductible for eachbenefit period. There is nolimit to the number of benefitperiods you can have.

In-NetworkContact the plan for detailsabout coverage in a PsychiatricHospital beyond 190 days.

In-NetworkContact the plan for detailsabout coverage in a PsychiatricHospital beyond 190 days.

In 2011 the amounts for eachbenefit period were:

4 Inpatient MentalHealth Care

Days 1 - 60: $1132deductible



Days 61 - 90: $283 perdayDays 91 - 150: $566 perlifetime reserve day



These amounts may changefor 2012.



You get up to 190 days ofinpatient psychiatric hospital



care in a lifetime. Inpatient The maximum out-of-pocketlimit is covered under"Inpatient Hospital Care".

Except in an emergency, yourdoctor must tell the plan thatyou are going to be admittedto the hospital.

psychiatric hospital servicescount toward the 190-daylifetime limitation only ifcertain conditions are met. Except in an emergency, your

doctor must tell the plan thatOut-of-NetworkFor hospital stays:

This limitation does not applyto inpatient psychiatric you are going to be admitted

to the hospital.services furnished in a generalhospital.

Days 1 - 7: $205 copay perday Out-of-Network

For hospital stays:






Days 8 and beyond: $0copay per day

Days 8 and beyond: $0copay per day

GeneralAuthorization rules mayapply.


In 2011 the amounts for eachbenefit period after at least a3-day covered hospital staywere:

5 Skilled NursingFacility (SNF)(in aMedicare-certifiedskilled nursingfacility)

In-NetworkPlan covers up to 100 dayseach benefit period

In-NetworkPlan covers up to 100 dayseach benefit period

Days 1 - 20: $0 per dayDays 21 - 100: $141.50per day No prior hospital stay is

required.No prior hospital stay isrequired.These amounts may change

for 2012.For SNF stays:For SNF stays:

100 days for each benefitperiod. Days 1 - 20: $0 copay per

dayDays 1 - 20: $0 copay perday

A "benefit period" starts theday you go into a hospital or

Days 21 - 100: $146 copayper day

Days 21 - 100: $146 copayper day

SNF. It ends when you go for Out-of-NetworkFor each SNF stay:

Out-of-NetworkFor each SNF stay:60 days in a row without

hospital or skilled nursingDays 1 - 20: $0 copay perSNF day

Days 1 - 20: $0 copay perSNF day

care. If you go into thehospital after one benefit

Days 21 - 100: $146 copayper SNF day

Days 21 - 100: $146 copayper SNF day

period has ended, a newbenefit period begins. Youmust pay the inpatienthospital deductible for eachbenefit period. There is nolimit to the number of benefitperiods you can have.







$0 copay.6 Home HealthCare(includesmedicallynecessaryintermittentskilled nursingcare, home healthaide services, andrehabilitationservices, etc.)

In-Network$0 copay for eachMedicare-covered homehealth visit

Out-of-Network$0 copay for home healthvisits

In-Network$0 copay for eachMedicare-covered homehealth visit

Out-of-Network$0 copay for home healthvisits

GeneralYou must get care from aMedicare-certified hospice.

GeneralYou must get care from aMedicare-certified hospice.

You pay part of the cost foroutpatient drugs and inpatientrespite care.

7 Hospice

Your plan will pay for aYour plan will pay for aYou must get care from aMedicare-certified hospice. consultative visit before you

select hospice.consultative visit before youselect hospice.

OUTPATIENT CARE

In-Network$15 copay for each primarycare doctor visit forMedicare-covered benefits.

In-Network$0 copay for each primary caredoctor visit forMedicare-covered benefits.

20% coinsurance8 Doctor OfficeVisits

$25 copay for each in-area,network urgent careMedicare-covered visit

$45 copay for each in-area,network urgent careMedicare-covered visit

$25 copay for each specialistvisit for Medicare-coveredbenefits.

$45 copay for each specialistvisit for Medicare-coveredbenefits.

Out-of-Network$25 copay for each specialistvisit

Out-of-Network$45 copay for each specialistvisit

$15 to $25 copay for eachprimary care doctor visit

$0 to $45 copay for eachprimary care doctor visit







Supplemental routine care notcovered

20% coinsurance for manualmanipulation of the spine to

9 ChiropracticServices

In-Network$20 copay for eachMedicare-covered visit


correct subluxation (adisplacement or misalignmentof a joint or body part) if you Medicare-covered chiropractic

visits are for manualMedicare-covered chiropracticvisits are for manualget it from a chiropractor or

other qualified providers. manipulation of the spine tomanipulation of the spine tocorrect subluxation (acorrect subluxation (adisplacement or misalignmentdisplacement or misalignmentof a joint or body part) if youof a joint or body part) if youget it from a chiropractor orother qualified providers.

get it from a chiropractor orother qualified providers.

Out-of-Network$20 copay for chiropracticbenefits.

Out-of-Network$20 copay for chiropracticbenefits.



Supplemental routine care notcovered.

20% coinsurance formedically necessary foot care,

10 Podiatry Services

Medicare-covered podiatrybenefits are formedically-necessary foot care.

Medicare-covered podiatrybenefits are formedically-necessary foot care.

including care for medicalconditions affecting the lowerlimbs. Out-of-Network

$25 copay for podiatrybenefits.

Out-of-Network$45 copay for podiatrybenefits.



40% coinsurance for mostoutpatient mental healthservices

11 OutpatientMental HealthCare

In-Network$40 copay for eachMedicare-covered individualtherapy visit

In-Network$40 copay for eachMedicare-covered individualtherapy visit

Specified copayment foroutpatient partialhospitalization programservices furnished by ahospital or community mental





$40 copay for eachMedicare-covered grouptherapy visit

$40 copay for eachMedicare-covered grouptherapy visit

health center (CMHC).Copay cannot exceed the PartA inpatient hospitaldeductible. $40 copay for each

Medicare-covered individual$40 copay for eachMedicare-covered individual"Partial hospitalization

program" is a structured therapy visit with apsychiatrist

therapy visit with apsychiatristprogram of active outpatient

psychiatric treatment that is $40 copay for eachMedicare-covered group

$40 copay for eachMedicare-covered groupmore intense than the care

received in your doctor's or therapy visit with apsychiatrist

therapy visit with apsychiatristtherapist's office and is an

alternative to inpatienthospitalization. $40 copay for

Medicare-covered partial$45 copay forMedicare-covered partial

hospitalization programservices


Out-of-Network$40 copay for Mental Healthbenefits with a psychiatrist

Out-of-Network$45 copay for partialhospitalization programservices $40 copay for Mental Health

benefits$40 copay for Mental Healthbenefits with a psychiatrist $40 copay for partial


$40 copay for Mental Healthbenefits



20% coinsurance12 OutpatientSubstance AbuseCare

In-Network$40 copay forMedicare-covered individualvisits

In-Network$40 copay forMedicare-covered individualvisits

$40 copay forMedicare-covered group visits

$40 copay forMedicare-covered group visits

Out-of-Network$40 copay for outpatientsubstance abuse benefits.

Out-of-Network$40 copay for outpatientsubstance abuse benefits.







20% coinsurance for thedoctor's services

Specified copayment foroutpatient hospital facility

13 OutpatientServices/Surgery

In-Network$0 to $150 copay for eachMedicare-covered ambulatorysurgical center visit

In-Network$0 to $250 copay for eachMedicare-covered ambulatorysurgical center visit

services Copay cannot exceedthe Part A inpatient hospitaldeductible.

$0 to $150 copay for eachMedicare-covered outpatienthospital facility visit

$0 to $250 copay for eachMedicare-covered outpatienthospital facility visit

20% coinsurance forambulatory surgical centerfacility services

Out-of-Network$0 to $150 copay foroutpatient hospital facilitybenefits.

Out-of-Network$0 to $250 copay foroutpatient hospital facilitybenefits.

$0 to $150 copay forambulatory surgical centerbenefits.

$0 to $250 copay forambulatory surgical centerbenefits.



20% coinsurance14 AmbulanceServices(medicallynecessaryambulanceservices)

In-Network$125 copay forMedicare-covered ambulancebenefits.

In-Network$175 copay forMedicare-covered ambulancebenefits.

Out-of-Network$125 copay for ambulancebenefits.

Out-of-Network$175 copay for ambulancebenefits.

General$65 copay forMedicare-covered emergencyroom visits

General$65 copay forMedicare-covered emergencyroom visits

20% coinsurance for thedoctor's services

Specified copayment foroutpatient hospital facilityemergency services.

15 Emergency Care(You may go toany emergencyroom if youreasonably believeyou needemergency care.)

Worldwide coverage.

If you are admitted to thehospital within 72-hour(s) for

Worldwide coverage.

If you are admitted to thehospital within 72-hour(s) for

Emergency services copaycannot exceed Part A inpatient

the same condition, you paythe same condition, you payhospital deductible for each





service provided by thehospital.

$0 for the emergency roomvisit.

$0 for the emergency roomvisit.

You don't have to pay theemergency room copay if youare admitted to the hospital asan inpatient for the samecondition within 3 days of theemergency room visit.

Not covered outside the U.S.except under limitedcircumstances.

General$25 copay forMedicare-coveredurgently-needed-care visits

General$45 copay forMedicare-coveredurgently-needed-care visits

20% coinsurance, or a setcopay

NOT covered outside theU.S. except under limitedcircumstances.

16 Urgently NeededCare(This is NOTemergency care,and in most cases,is out of theservice area.)



20% coinsurance17 OutpatientRehabilitationServices(OccupationalTherapy, PhysicalTherapy, Speechand LanguageTherapy)

In-Network$60 copay forMedicare-coveredOccupational Therapy visits

$60 copay forMedicare-covered Physical

In-Network$65 copay forMedicare-coveredOccupational Therapy visits

$65 copay forMedicare-covered Physical

and/or Speech and LanguageTherapy visits

and/or Speech and LanguageTherapy visits

Out-of-Network$60 copay for Physical and/orSpeech and Language Therapyvisits

Out-of-Network$65 copay for Physical and/orSpeech and Language Therapyvisits

$60 copay for OccupationalTherapy benefits.

$65 copay for OccupationalTherapy benefits.





Outpatient Medical Services and Supplies



20% coinsurance18 Durable MedicalEquipment(includeswheelchairs,oxygen, etc.) In-Network

20% of the cost forMedicare-covered items

In-Network20% of the cost forMedicare-covered items

Out-of-Network20% of the cost for durablemedical equipment

Out-of-Network20% of the cost for durablemedical equipment



20% coinsurance19 ProstheticDevices(includes braces,artificial limbsand eyes, etc.) In-Network

20% of the cost forMedicare-covered items

In-Network20% of the cost forMedicare-covered items

Out-of-Network20% of the cost for prostheticdevices.

Out-of-Network20% of the cost for prostheticdevices.

In-Network$0 copay for Diabetesself-management training

In-Network$0 copay for Diabetesself-management training

20% coinsurance for diabetesself-management training

20% coinsurance for diabetessupplies

20 DiabetesPrograms andSupplies

$0 copay for Diabetesmonitoring supplies

$0 copay for Diabetesmonitoring supplies20% coinsurance for diabetic

therapeutic shoes or inserts $0 copay for Therapeuticshoes or inserts

$0 copay for Therapeuticshoes or inserts

Out-of-Network$0 copay for Diabetesself-management training

Out-of-Network$0 copay for Diabetesself-management training











20% coinsurance fordiagnostic tests and x-rays

$0 copay forMedicare-covered lab services

21 Diagnostic Tests,X-Rays, LabServices, andRadiologyServices In-Network

$0 copay forMedicare-covered lab services

In-Network$0 copay forMedicare-covered lab services

Lab Services: Medicare coversmedically necessary diagnosticlab services that are ordered $0 to $130 copay for

Medicare-covered diagnosticprocedures and tests

$0 to $160 copay forMedicare-covered diagnosticprocedures and tests

by your treating doctor whenthey are provided by a ClinicalLaboratory Improvement $70 copay for

Medicare-covered X-rays$100 copay forMedicare-covered X-raysAmendments (CLIA) certified

laboratory that participates in$70 to $130 copay forMedicare-covered diagnostic

$100 to $160 copay forMedicare-covered diagnostic

Medicare. Diagnostic labservices are done to help your

radiology services (notincluding X-rays)

radiology services (notincluding X-rays)

doctor diagnose or rule out asuspected illness or condition.Medicare does not cover most 20% of the cost for

Medicare-covered therapeuticradiology services

20% of the cost forMedicare-covered therapeuticradiology services

supplemental routinescreening tests, like checkingyour cholesterol.

If the doctor provides youservices in addition to


Outpatient DiagnosticOutpatient DiagnosticProcedures, Tests and LabProcedures, Tests and LabServices, separate cost sharingof $15 to $25 may apply

Services, separate cost sharingof $0 to $45 may apply



Outpatient Diagnostic andOutpatient Diagnostic andTherapeutic RadiologyTherapeutic RadiologyServices, separate cost sharingof $15 to $25 may apply

Services, separate cost sharingof $0 to $45 may apply

Out-of-Network$0 to $130 copay fordiagnostic procedures, tests,and lab services

Out-of-Network$0 to $160 copay fordiagnostic procedures, tests,and lab services

20% of the cost fortherapeutic radiology services

20% of the cost fortherapeutic radiology services





$70 to $130 copay foroutpatient X-rays

$100 to $160 copay foroutpatient X-rays

$70 to $130 copay fordiagnostic radiology services

$100 to $160 copay fordiagnostic radiology services

In-Network$0 copay forMedicare-covered CardiacRehabilitation Services

In-Network$0 copay forMedicare-covered CardiacRehabilitation Services

20% coinsurance CardiacRehabilitation services

20% coinsurance forPulmonary Rehabilitationservices

22 Cardiac andPulmonaryRehabilitationServices

$0 copay forMedicare-covered Intensive

$0 copay forMedicare-covered Intensive20% coinsurance for Intensive

Cardiac Rehabilitation services Cardiac RehabilitationServices

Cardiac RehabilitationServices

This applies to programservices provided in a doctor's $0 copay for

Medicare-covered PulmonaryRehabilitation Services

$0 copay forMedicare-covered PulmonaryRehabilitation Services

office. Specified cost sharingfor program services providedby hospital outpatientdepartments.

Out-of-Network$0 copay for CardiacRehabilitation Services

Out-of-Network$0 copay for CardiacRehabilitation Services

$0 copay for Intensive CardiacRehabilitation Services

$0 copay for Intensive CardiacRehabilitation Services

$0 copay for PulmonaryRehabilitation Services

$0 copay for PulmonaryRehabilitation Services

PREVENTIVE SERVICES

General$0 copay for all preventiveservices covered under

General$0 copay for all preventiveservices covered under

No coinsurance, copaymentor deductible for thefollowing:

23 PreventiveServices andWellness/EducationPrograms

Original Medicare at zero costsharing:

Original Medicare at zero costsharing:

Abdominal AorticAneurysm Screening

Abdominal AorticAneurysm screening

Abdominal AorticAneurysm screening

Bone Mass Measurement.Covered once every 24months (more often ifmedically necessary) if youmeet certain medicalconditions.

Bone Mass MeasurementBone Mass MeasurementCardiovascular Screening Cardiovascular Screening





Cervical and VaginalCancer Screening (PapTest and Pelvic Exam)

Cervical and VaginalCancer Screening (PapTest and Pelvic Exam)

Cardiovascular ScreeningCervical and VaginalCancer Screening. Coveredonce every 2 years.Covered once a year forwomen with Medicare athigh risk.

Colorectal CancerScreening

Colorectal CancerScreeningDiabetes Screening Diabetes Screening

Influenza VaccineInfluenza VaccineColorectal CancerScreening

Hepatitis B VaccineHepatitis B VaccineHIV ScreeningHIV Screening

Diabetes Screening Breast Cancer Screening(Mammogram)

Breast Cancer Screening(Mammogram)Influenza Vaccine

Hepatitis B Vaccine forpeople with Medicare whoare at risk

Medical NutritionTherapy Services

Medical NutritionTherapy Services

Personalized PreventionPlan Services (AnnualWellness Visits)

Personalized PreventionPlan Services (AnnualWellness Visits)

HIV Screening. $0 copayfor the HIV screening, butyou generally pay 20% ofthe Medicare-approvedamount for the doctor'svisit. HIV screening iscovered for people withMedicare who arepregnant and people atincreased risk for theinfection, includinganyone who asks for thetest. Medicare covers thistest once every 12 monthsor up to three times duringa pregnancy.

Pneumococcal VaccinePneumococcal VaccineProstate Cancer Screening(Prostate Specific Antigen(PSA) test only)

Prostate Cancer Screening(Prostate Specific Antigen(PSA) test only)Smoking Cessation(Counseling to stopsmoking)

Smoking Cessation(Counseling to stopsmoking)Welcome to MedicarePhysical Exam (InitialPreventive Physical Exam)

Welcome to MedicarePhysical Exam (InitialPreventive Physical Exam)

HIV screening is covered forpeople with Medicare who arepregnant and people atincreased risk for theinfection, including anyone

HIV screening is covered forpeople with Medicare who arepregnant and people atincreased risk for theinfection, including anyoneBreast Cancer Screening

(Mammogram). Medicarecovers screeningmammograms once every12 months for all womenwith Medicare age 40 andolder. Medicare covers onebaseline mammogram forwomen between ages35-39.

who asks for the test.Medicare covers this test onceevery 12 months or up tothree times during apregnancy. Please contact planfor details.

In-NetworkThe plan covers the followingsupplemental education/wellness programs:

who asks for the test.Medicare covers this test onceevery 12 months or up tothree times during apregnancy. Please contact planfor details.

In-NetworkThe plan covers the followingsupplemental education/wellness programs:





Medical NutritionTherapy Services Nutritiontherapy is for people whohave diabetes or kidneydisease (but aren't ondialysis or haven't had akidney transplant) whenreferred by a doctor. Theseservices can be given by aregistered dietitian andmay include a nutritionalassessment and counselingto help you manage yourdiabetes or kidney disease

Health Club Membership/Fitness Classes

Health Club Membership/Fitness ClassesNursing Hotline Nursing Hotline

Out-of-Network$0 copay forMedicare-covered preventiveservices

$0 copay for supplementaleducation/wellness programs

Out-of-Network$0 copay forMedicare-covered preventiveservices

$0 copay for supplementaleducation/wellness programs

Personalized PreventionPlan Services (AnnualWellness Visits)Pneumococcal Vaccine.You may only need thePneumonia vaccine oncein your lifetime. Call yourdoctor for moreinformation.Prostate CancerScreening - ProstateSpecific Antigen (PSA) testonly. Covered once a yearfor all men with Medicareover age 50.Smoking Cessation(counseling to stopsmoking). Covered ifordered by your doctor.Includes two counselingattempts within a12-month period. Eachcounseling attemptincludes up to fourface-to-face visits.





Welcome to MedicarePhysical Exam (initialpreventive physical exam)When you join MedicarePart B, then you areeligible as follows. Duringthe first 12 months of yournew Part B coverage, youcan get either a Welcometo Medicare Physical Examor an Annual WellnessVisit. After your first 12months, you can get oneAnnual Wellness Visitevery 12 months.

In-Network20% of the cost for renaldialysis

In-Network20% of the cost for renaldialysis

20% coinsurance for renaldialysis

20% coinsurance for kidneydisease education services

24 Kidney Diseaseand Conditions

$0 copay for kidney diseaseeducation services

$0 copay for kidney diseaseeducation services

Out-of-Network$0 copay for kidney diseaseeducation services

Out-of-Network$0 copay for kidney diseaseeducation services

20% of the cost for renaldialysis

20% of the cost for renaldialysis

Drugs Covered UnderMedicare Part BGeneral20% of the cost for PartB-covered chemotherapy

Drugs Covered UnderMedicare Part BGeneral20% of the cost for PartB-covered chemotherapy

Most drugs are not coveredunder Original Medicare. Youcan add prescription drugcoverage to Original Medicareby joining a Medicare

25 OutpatientPrescriptionDrugs

drugs and other PartB-covered drugs.

drugs and other PartB-covered drugs.

Prescription Drug Plan, oryou can get all your Medicarecoverage, including 20% of the cost for Part B

drugs out-of-network.20% of the cost for Part Bdrugs out-of-network.prescription drug coverage, by

joining a Medicare Advantage





Drugs Covered UnderMedicare Part DGeneralThis plan uses a formulary.The plan will send you the

Drugs Covered UnderMedicare Part DGeneralThis plan uses a formulary.The plan will send you the

Plan or a Medicare Cost Planthat offers prescription drugcoverage.

formulary. You can also seeformulary. You can also seethe formulary atwww.anthem.com on the web.

the formulary atwww.anthem.com on the web.

Different out-of-pocket costsmay apply for people who

Different out-of-pocket costsmay apply for people who

have limited incomes,have limited incomes,live in long term carefacilities, or

live in long term carefacilities, orhave access to Indian/Tribal/Urban (IndianHealth Service) providers.

have access to Indian/Tribal/Urban (IndianHealth Service) providers.

The plan offers nationalin-network prescription

The plan offers nationalin-network prescription

coverage (i.e., this would coverage (i.e., this wouldinclude 50 states and the include 50 states and theDistrict of Columbia). This District of Columbia). Thismeans that you will pay the means that you will pay thesame cost-sharing amount for same cost-sharing amount foryour prescription drugs if you your prescription drugs if youget them at an in-network get them at an in-networkpharmacy outside of the plan's pharmacy outside of the plan'sservice area (for instance whenyou travel).

service area (for instance whenyou travel).

Total yearly drug costs are thetotal drug costs paid by bothyou and a Part D plan.

Total yearly drug costs are thetotal drug costs paid by bothyou and a Part D plan.

The plan may require you tofirst try one drug to treat your

The plan may require you tofirst try one drug to treat your

condition before it will cover condition before it will coveranother drug for thatcondition.

another drug for thatcondition.

Some drugs have quantitylimits.

Some drugs have quantitylimits.





Your provider must get priorauthorization from Anthem

Your provider must get priorauthorization from Anthem

Medicare Preferred Standard(PPO) for certain drugs.

Medicare Preferred Premier(PPO) for certain drugs.

You must go to certainpharmacies for a very limited

You must go to certainpharmacies for a very limited

number of drugs, due to number of drugs, due tospecial handling, provider special handling, providercoordination, or patient coordination, or patienteducation requirements that education requirements thatcannot be met by most cannot be met by mostpharmacies in your network. pharmacies in your network.These drugs are listed on the These drugs are listed on theplan's website, formulary, plan's website, formulary,printed materials, as well as on printed materials, as well as onthe Medicare Prescription the Medicare PrescriptionDrug Plan Finder onMedicare.gov.

Drug Plan Finder onMedicare.gov.

If the actual cost of a drug isless than the normal

If the actual cost of a drug isless than the normal

cost-sharing amount for that cost-sharing amount for thatdrug, you will pay the actual drug, you will pay the actualcost, not the highercost-sharing amount.

cost, not the highercost-sharing amount.

You pay $0 the first time youfill a prescription for certain

You pay $0 the first time youfill a prescription for certain

drugs. These drugs will be drugs. These drugs will belisted as "free first fill" on the listed as "free first fill" on theplan's website, formulary, plan's website, formulary,printed materials, and on the printed materials, and on theMedicare Prescription DrugPlan Finder on Medicare.gov.

Medicare Prescription DrugPlan Finder on Medicare.gov.

If you request a formularyexception for a drug and

If you request a formularyexception for a drug and

Anthem Medicare Preferred Anthem Medicare PreferredStandard (PPO) approves the Premier (PPO) approves theexception, you will pay Tier exception, you will pay Tier3: Non-Preferred Brand 3: Non-Preferred BrandDrugs cost sharing for thatdrug.

Drugs cost sharing for thatdrug.





In-Network$60 deductible on all drugsexcept Tier 1: Generic Drugs,

In-Network$60 deductible on all drugsexcept Tier 1: Generic Drugs,

Tier 4: Injectable Drugs, TierTier 4: Injectable Drugs, Tier5: Specialty Tier Drugs, Tier6: Supplemental Drugs.

5: Specialty Tier Drugs, Tier6: Supplemental Drugs.

Supplemental drugs don'tcount toward yourout-of-pocket drug costs.

Supplemental drugs don'tcount toward yourout-of-pocket drug costs.

Initial CoverageAfter you pay your yearlydeductible, you pay the

Initial CoverageAfter you pay your yearlydeductible, you pay the

following until total yearlydrug costs reach $2,930:

following until total yearlydrug costs reach $2,930:

Retail PharmacyTier 1: Generic Drugs


$7 copay for a one-month(30-day) supply of drugsin this tier

$0 copay for a one-month(30-day) supply of drugsin this tier$0 copay for athree-month (90-day)supply of drugs in this tier

$21 copay for athree-month (90-day)supply of drugs in this tier

Tier 2: Preferred Brand DrugsTier 2: Preferred Brand Drugs

$43 copay for aone-month (30-day)supply of drugs in this tier

$43 copay for aone-month (30-day)supply of drugs in this tier$129 copay for athree-month (90-day)supply of drugs in this tier


Tier 3: Non-Preferred BrandDrugs



$85 copay for aone-month (30-day)supply of drugs in this tier$255 copay for athree-month (90-day)supply of drugs in this tier






Tier 4: Injectable DrugsTier 4: Injectable Drugs

33% coinsurance for aone-month (30-day)supply of drugs in this tier

33% coinsurance for aone-month (30-day)supply of drugs in this tier33% coinsurance for athree-month (90-day)supply of drugs in this tier

33% coinsurance for athree-month (90-day)supply of drugs in this tier

Tier 5: Specialty Tier DrugsTier 5: Specialty Tier Drugs



Tier 6: Supplemental Drugs Tier 6: Supplemental Drugs


$7 copay for a one-month(30-day) supply of drugsin this tier$21 copay for athree-month (90-day)supply of drugs in this tier


Long-Term Care PharmacyTier 1: Generic Drugs




Tier 2: Preferred Brand Drugs Tier 2: Preferred Brand Drugs







Tier 4: Injectable Drugs Tier 4: Injectable Drugs













Mail OrderTier 1: Generic Drugs


$10.50 copay for athree-month (90-day)supply of drugs in this tier


















Coverage GapAfter your total yearly drugcosts reach $2,930, you





receive a discount on brandname drugs and pay 86% ofthe plan's costs for all genericdrugs until your yearlyout-of-pocket drug costs reach$4,700.

Additional Coverage GapThe plan covers manyformulary generics (65%-99%of formulary generic drugs)through the coverage gap.

You pay the following:


$7 copay for a one-month(30-day) supply of alldrugs covered in this tier$21 copay for athree-month (90-day)supply of all drugs coveredin this tier

Tier 6: Supplemental Drugs

$7 copay for a one-month(30-day) supply of alldrugs covered in this tier$21 copay for athree-month (90-day)supply of all drugs coveredin this tier


$7 copay for a one-month(34-day) supply of alldrugs covered in this tier








$10.50 copay for athree-month (90-day)supply of all drugs coveredin this tier


$10.50 copay for athree-month (90-day)supply of all drugs coveredin this tier

After your total yearly drugcosts reach $2,930, youreceive limited coverage by theplan on certain drugs. Youwill also receive a discount onbrand name drugs andgenerally pay no more than86% of the plan's costs forgeneric drugs until your yearlyout-of-pocket drug costs reach$4,700.

Catastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

Catastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

$4,700, you pay the greaterof:

$4,700, you pay the greaterof:

5% coinsurance, or5% coinsurance, or$2.60 copay for generic(including brand drugstreated as generic) and a$6.50 copay for all otherdrugs.

$2.60 copay for generic(including brand drugstreated as generic) and a$6.50 copay for all otherdrugs.

Tier 6: Supplemental DrugsTier 6: Supplemental Drugs





$7 copay for drugs in thistier


Out-of-NetworkPlan drugs may be covered inspecial circumstances, for

Out-of-NetworkPlan drugs may be covered inspecial circumstances, for

instance, illness while travelinginstance, illness while travelingoutside of the plan's serviceoutside of the plan's servicearea where there is no networkarea where there is no networkpharmacy. You may have topharmacy. You may have topay more than your normalpay more than your normalcost-sharing amount if you getcost-sharing amount if you getyour drugs at anyour drugs at anout-of-network pharmacy. Inout-of-network pharmacy. Inaddition, you will likely haveaddition, you will likely haveto pay the pharmacy's fullto pay the pharmacy's fullcharge for the drug andcharge for the drug andsubmit documentation tosubmit documentation toreceive reimbursement fromreceive reimbursement fromAnthem Medicare PreferredPremier (PPO).

Anthem Medicare PreferredStandard (PPO).

Out-of-Network InitialCoverageAfter you pay your yearlydeductible, you will be

Out-of-Network InitialCoverageAfter you pay your yearlydeductible, you will be

reimbursed up to the plan'sreimbursed up to the plan'scost of the drug minus thecost of the drug minus thefollowing for drugs purchasedfollowing for drugs purchasedout-of-network until yourout-of-network until yourtotal yearly drug costs reach$2,930:

total yearly drug costs reach$2,930:

Tier 1: Generic DrugsTier 1: Generic Drugs























You will not be reimbursedfor the difference between the


Out-of-Network PharmacyOut-of-Network Pharmacycharge and the plan'scharge and the plan'sIn-Network allowableamount.

In-Network allowableamount.

Additional Out-of-NetworkCoverage GapYou will be reimbursed forthese drugs purchased

Additional Out-of-NetworkCoverage GapYou will be reimbursed up to14% of the plan allowable cost

out-of-network up to thefor generic drugs purchasedplan's cost of the drug minusthe following:

out-of-network until totalyearly out-of-pocket drugcosts reach $4,700. Tier 1: Generic DrugsYou will be reimbursed up tothe discounted price for brand

$7 copay for a one-month(30-day) supply of alldrugs covered in this tiername drugs purchased

out-of-network until total Tier 2: Preferred Brand Drugsyearly out-of-pocket drugcosts reach $4,700.






You will be reimbursed upto 14% of the planallowable cost for genericdrugs purchasedout-of-network until totalyearly out-of-pocket drugcosts reach $4,700.

Out-of-Network Pharmacycharge and the plan'sIn-Network allowableamount.

You will be reimbursed up tothe discounted price for brandname drugs purchasedout-of-network until totalyearly out-of-pocket drugcosts reach $4,700.




Tier 4: Injectable Drugs


You will be reimbursed up tothe discounted price for brandname drugs purchasedout-of-network until total





yearly out-of-pocket drugcosts reach $4,700.

Tier 5: Specialty Tier Drugs





You will not be reimbursedfor the difference between theOut-of-Network Pharmacycharge and the plan'sIn-Network allowableamount.

Out-of-NetworkCatastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

Out-of-NetworkCatastrophic CoverageAfter your yearlyout-of-pocket drug costs reach

$4,700, you will be$4,700, you will bereimbursed for drugsreimbursed for drugspurchased out-of-network uppurchased out-of-network upto the plan's cost of the drugto the plan's cost of the drugminus your cost share, whichis the greater of:

minus your cost share, whichis the greater of:

5% coinsurance, or5% coinsurance, or







Tier 6: Supplemental DrugsTier 6: Supplemental Drugs





Out-of-Network Pharmacy Out-of-Network Pharmacycharge and the plan's charge and the plan'sIn-Network allowableamount.

In-Network allowableamount.

In-NetworkIn general, preventive dentalbenefits (such as cleaning) notcovered.

In-NetworkIn general, preventive dentalbenefits (such as cleaning) notcovered.

Preventive dental services(such as cleaning) not covered.

26 Dental Services

However, this plan coverspreventive dental benefits for

However, this plan coverspreventive dental benefits for

an extra cost (see "OptionalBenefits.")

an extra cost (see "OptionalBenefits.")

0% of the cost forMedicare-covered dentalbenefits

0% of the cost forMedicare-covered dentalbenefits

Out-of-Network$0 copay for comprehensivedental benefits

Out-of-Network$0 copay for comprehensivedental benefits

In-NetworkIn general, supplementalroutine hearing exams andhearing aids not covered.

In-NetworkIn general, supplementalroutine hearing exams andhearing aids not covered.

Supplemental routine hearingexams and hearing aids notcovered.

20% coinsurance fordiagnostic hearing exams.

27 Hearing Services

$25 copay forMedicare-covereddiagnostic hearing exams

$45 copay forMedicare-covereddiagnostic hearing exams





Out-of-Network$45 copay for hearing exams.

Out-of-Network$25 copay for hearing exams.

In-NetworkIn general, supplementalroutine eye exams and eye

In-NetworkIn general, supplementalroutine eye exams and eye

20% coinsurance for diagnosisand treatment of diseases andconditions of the eye.

28 Vision Services

wear not covered. However,wear not covered. However,Supplemental routine eyeexams and glasses not covered. this plan covers some vision

benefits for an extra cost (see"Optional Benefits").

this plan covers some visionbenefits for an extra cost (see"Optional Benefits").Medicare pays for one pair of

eyeglasses or contact lensesafter cataract surgery. $0 copay for one pair of

eyeglasses or contact lensesafter cataract surgery.

$0 copay for one pair ofeyeglasses or contact lensesafter cataract surgery.Annual glaucoma screenings

covered for people at risk. $0 copay for exams todiagnose and treat diseasesand conditions of the eye.

$0 copay for exams todiagnose and treat diseasesand conditions of the eye.

Out-of-Network$0 copay for eye exams.


$0 copay for eye wear. $0 copay for eye wear.

GeneralThe plan does not coverOver-the-Counter items.

GeneralThe plan does not coverOver-the-Counter items.

Not covered.Over-the-CounterItems

In-NetworkThis plan does not coversupplemental routinetransportation.

In-NetworkThis plan does not coversupplemental routinetransportation.

Not covered.Transportation(Routine)

In-NetworkThis plan does not coverAcupuncture.

In-NetworkThis plan does not coverAcupuncture.

Not covered.Acupuncture





OPTIONAL SUPPLEMENTAL PACKAGE #1

GeneralPackage: 1 - Preventive DentalPackage:

GeneralPackage: 1 - Preventive DentalPackage:

Premium and OtherImportantInformation

$12 monthly premium, inaddition to your $39 monthly


plan premium and theplan premium and themonthly Medicare Part Bmonthly Medicare Part Bpremium, for the followingoptional benefits:

premium, for the followingoptional benefits:

Preventive DentalPreventive Dental

In-Network$0 copay for the followingpreventive dental benefits:

In-Network$0 copay for the followingpreventive dental benefits:

Dental Services

up to 2 oral exam(s) everyyear

up to 2 oral exam(s) everyyearup to 2 cleaning(s) everyyear

up to 2 cleaning(s) everyyearup to 1 dental x-ray(s)every year

up to 1 dental x-ray(s)every year

Out-of-Network20% of the cost for preventivedental services


In and Out-of-Network$500 plan coverage limit forpreventive dental benefits

In and Out-of-Network$500 plan coverage limit forpreventive dental benefits

every year. This limit applies every year. This limit appliesto both in-network andout-of-network benefits.

to both in-network andout-of-network benefits.


GeneralPackage: 2 - ComprehensiveDental and Vision Package:

GeneralPackage: 2 - ComprehensiveDental and Vision Package:










Preventive DentalPreventive DentalComprehensive Dental Comprehensive Dental

Eye ExamsEye ExamsEye Wear Eye Wear

In-NetworkIn-NetworkDental Services$0 copay for up to 2cleaning(s) every year

$0 copay for up to 2cleaning(s) every year$0 copay for up to 2 oralexam(s) every year

$0 copay for up to 2 oralexam(s) every year$0 copay for up to 1 dentalx-ray(s) every year

$0 copay for up to 1 dentalx-ray(s) every year



30% to 75% of the cost forcomprehensive dental services


In and Out-of-Network$1,000 plan coverage limit fordental benefits every year.


This limit applies to both This limit applies to bothin-network andout-of-network benefits.

in-network andout-of-network benefits.

Contact the plan foravailability of additional


in-network and in-network andout-of-networkcomprehensive dental benefits.

out-of-networkcomprehensive dental benefits.

In-Network$0 copay for:

In-Network$0 copay for:

Vision Services





and up to 1 supplementalroutine eye exam(s) everyyear

and up to 1 supplementalroutine eye exam(s) everyyear

$0 copay for $0 copay for

up to 1 pair(s) of glassesevery year

up to 1 pair(s) of glassesevery yearup to 1 pair(s) of contactsevery year

up to 1 pair(s) of contactsevery year


GeneralPackage: 3 - CombinationPackage:

GeneralPackage: 3 - CombinationPackage:






Chiropractic ServicesChiropractic ServicesAcupuncture Acupuncture

Preventive DentalPreventive DentalComprehensive Dental Comprehensive Dental

Eye ExamsEye ExamsEye Wear Eye Wear

In-Network$20 copay for up to 10supplemental routine visit(s)every year

In-Network$20 copay for up to 10supplemental routine visit(s)every year

Chiropractic Services

Out-of-Network$30 copay for chiropracticservices

Out-of-Network$30 copay for chiropracticservices





In-NetworkIn-NetworkDental Services$0 copay for up to 2cleaning(s) every year

$0 copay for up to 2cleaning(s) every year$0 copay for up to 2 oralexam(s) every year

$0 copay for up to 2 oralexam(s) every year$0 copay for up to 1 dentalx-ray(s) every year

$0 copay for up to 1 dentalx-ray(s) every year







This limit applies to both This limit applies to bothin-network andout-of-network benefits.

in-network andout-of-network benefits.



in-network and in-network andout-of-networkcomprehensive dental benefits.

out-of-networkcomprehensive dental benefits.

In-NetworkIn-NetworkVision Services$0 copay for up to 1pair(s) of contacts everyyear

$0 copay for up to 1pair(s) of contacts everyyear$0 copay for up to 1pair(s) of glasses every year

$0 copay for up to 1pair(s) of glasses every year$0 copay for up to 1supplemental routine eyeexam(s) every year

$0 copay for up to 1supplemental routine eyeexam(s) every year



$0 copay for eye wear. $0 copay for eye wear.


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