anthem blue cross and blue shield - h4036 cy 2013 medicare ... · tagalog: mayroon kaming libreng...

• How our members rate our plan's services and care;

• How well our doctors detect illnesses and keep members healthy;

• How well our plan helps our members use recommended and safe prescription medications

Image description. 4 Stars End of image description.

4 Stars

Image description. 5 stars End of image description.




Image description. 1 star End of image description.

The number of stars shows how well our plan performs.

excellent above average average below average poor

Anthem Blue Cross and Blue Shield - H4036

CY 2013 Medicare Plan Ratings

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality andperformance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Ratingto compare our plan's performance to other plans. Examples of the areas covered by this rating include:

For 2013, Anthem Blue Cross and Blue Shield received the following overall Plan Rating from Medicare.

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00p.m. Central at 800-797-5940 (toll-free) or 711 (TTY/TDD).

Current members please call 800-467-1199 (toll-free) or 711 (TTY/TDD).

Y0071_13_16155_U CMS Accepted 33577WISENABS

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-467-1199. Someone who speaks English/ Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-467-1199. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电 1-800-467-1199。我们的中文工作人员很乐意帮助您。这是一项免费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電1-800-467-1199。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-467-1199. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-467-1199. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-467-1199 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí.

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-467-1199. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하 고 있습니다. 통역 서비스를 이용하려면 전화 1-800-467-1199 번으로 문의해 주십시오. 한국어를 하 는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-467-1199. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا .

سيقوم شخص1-008-764-9911.للحصول على مترجم فوري، ليس عليك سوى االتصال بنا على. ما يتحدث العربية بمساعدتك. هذه خدمة مجانية

Hindi: हमार ेसवासथय या दवा की योजना क ेबार ेमे ंआपक ेिकसी भी पशन क ेजवाब देन ेक ेिलए हमार ेपास मुफत दुभािषया सेवाए ँउपलबध हैं. एक दुभाियषा परापत करन ेक ेिलए, बस हमे ं1-800-467-1199 पर फोन करें. कोई वयिकत जो िहनदी बोलता ह ैआपकी मदद कर सकता है. यह एक मुफत सेवा है.

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-467-1199. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-467-1199. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-467-1199. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-467-1199. Ta usługa jest bezpłatna.

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、1-800-467-1199 にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

Y0071_14_18283_U_001 CMS Accepted 30879MUSMLMUB_001

AD06553

Typewritten Text

Summary of Benefitsfor Anthem Medicare Preferred Core (PPO)

Available in Brown, Calumet, Fond du Lac, Green Lake, Jefferson, Manitowoc,Outagamie, Ozaukee, Shawano, Sheboygan, Washington, and WinnebagoCounties, WI

Anthem Blue Cross and Blue Shield is an LPPO plan with a Medicare contract. Enrollment in AnthemBlue Cross and Blue Shield depends on contract renewal. Anthem Insurance Companies, Inc. (AICI) isthe legal entity that has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer theLPPO plan noted above or herein. AICI is the risk-bearing entity licensed under applicable state law tooffer the LPPO plan(s) noted. AICI has retained the services of its related companies and the authorizedagents/brokers/producers to provide administrative services and/or to make the LPPO plan(s) available inthis region. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin(BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health ServicesInsurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare andBCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the BlueCross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and BlueShield Association.

Y0071_14_17593_U_025 CMS Accepted 10/01/2013 38887WPSENMUB_025H4036_004_WI_LPPO

Section I:

Introduction to Summary of BenefitsThank you for your interest in Anthem Medicare Preferred Core (PPO). Our plan is offered by Anthem InsuranceCompanies, Inc. which is also called Anthem Blue Cross and Blue Shield, a Medicare Advantage Preferred ProviderOrganization (PPO) that contracts with the Federal government. This Summary of Benefits tells you some featuresof our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of ourbenefits, please call Anthem Medicare Preferred Core (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 PreferredCore (PPO). You may have other options too. You makethe choice. No matter what you decide, you are still inthe Medicare Program.

You may be able to join or leave a plan only at certaintimes. Please call Anthem Medicare Preferred Core (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 Core(PPO) and the Original Medicare Plan using thisSummary of Benefits. The charts in this booklet list someimportant health benefits. For each benefit, you can seewhat our plan covers and what the Original MedicarePlan 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 is Anthem Medicare PreferredCore (PPO) available?The service area for this plan includes:

Brown, Calumet, Fond du Lac, Green Lake, Jefferson,Manitowoc, Outagamie, Ozaukee, Shawano, Sheboygan,Washington, Winnebago Counties, WI.

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

Who is eligible to join AnthemMedicare Preferred Core (PPO)?You can join Anthem Medicare Preferred Core (PPO) ifyou are entitled to Medicare Part A and enrolled inMedicare Part B and live in the service area. However,individuals with End-Stage Renal Disease generally arenot eligible to enroll in Anthem Medicare Preferred Core(PPO) unless they are members of our organization andhave been since their dialysis began.

Can I choose my doctors?Anthem Medicare Preferred Core (PPO) has 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 athttp://www.anthem.com/medicare. Our customerservice number is listed at the end of this introduction.

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.

Page 2 – Anthem Medicare Preferred Core (PPO)

Where can I get my prescriptions if Ijoin this plan?Anthem Medicare Preferred Core (PPO) has 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 athttp://www.anthem.com/medicare. Our customerservice number is listed at the end of this introduction.

Anthem Medicare Preferred Core (PPO) has a list ofpreferred pharmacies. At these pharmacies, you may getyour drugs at a lower co-pay or co-insurance. You maygo to a non-preferred pharmacy, but you may have topay more for your prescription drugs.

What if my doctor prescribes less thana month's supply?In consultation with your doctor or pharmacist, you mayreceive less than a month's supply of certain drugs. Also,if you live in a long-term care facility, you will receiveless than a month's supply of certain brand and genericdrugs. Dispensing fewer drugs at a time can help reducecost and waste in the Medicare Part D program, whenthis is medically appropriate.

The amount you pay in these circumstances will dependon whether you are responsible for paying coinsurance(a percentage of the cost of the drug) or a copay (a flatdollar amount for the drug). If you are responsible forcoinsurance for the drug, you will continue to pay theapplicable percentage of the drug cost. If you areresponsible for a copay for the drug, a "daily cost-sharingrate" will be applied. If your doctor decides to continuethe drug after a trial period, you should not pay more fora month's supply than you otherwise would have paid.Contact your plan if you have questions aboutcost-sharing when less than a one-month supply isdispensed.

Does my plan cover Medicare Part Bor Part D drugs?Anthem Medicare Preferred Core (PPO) does cover bothMedicare Part B prescription drugs and Medicare PartD prescription drugs.

What is a prescription drug formulary?Anthem Medicare Preferred Core (PPO) uses a formulary.A formulary is a list of drugs covered by your plan tomeet patient needs. We may periodically add, remove,or make changes to coverage limitations on certain drugsor change how much you pay for a drug. If we make anyformulary change that limits our members' ability to filltheir prescriptions, we will notify the affected membersbefore the change is made. We will send a formulary toyou and you can see our complete formulary on our Website at http://www.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 http://www.medicare.gov 'Programsfor People with Limited Income and Resources' in thepublication Medicare & 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 this plan?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 Core (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 ImprovementOrganization (QIO) for your state. Please refer to theEvidence of Coverage (EOC) for the QIO contactinformation.

As a member of Anthem Medicare Preferred Core (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. You

may 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 Core (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 Core (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 osteoporosis drugs forsome women.Erythropoietin: By injection if you have end-stagerenal disease (permanent kidney failure requiringeither dialysis or transplantation) and need this drugto 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 tookplace in a Medicare-certified facility and was paid forby Medicare or by a private insurance company thatwas the primary payer for Medicare Part A coverage.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 throughDurable Medical Equipment.

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 can find the Plan Ratingsinformation by using the “Find health & drug plans”web tool on http://www.medicare.gov to compare theplan ratings for Medicare plans in your area. You canalso call us directly to obtain a copy of the Plan Ratingsfor this plan. Our customer service number is listedbelow.

Please call Anthem Blue Cross and Blue Shield for more information aboutAnthem Medicare Preferred Core (PPO) Visit us at http://www.anthem.com/medicare or, call us:

Customer Service Hours for October 1 – February 14: Sunday, Monday, Tuesday,Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Central Customer Service Hours for February 15 – September 30: Monday, Tuesday,Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Central Current members should call toll-free 1-800-467-1199 for questions related to theMedicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD 711) Prospective members should call toll-free 1-800-797-5940 for questions related tothe Medicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD711) Current members should call locally 1-800-467-1199 for questions related to theMedicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD 711) Prospective members should call locally 1-800-797-5940 for questions related tothe Medicare Advantage and Medicare Part D Prescription Drug Program. (TTY/TDD711)


For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours aday, 7 days a week. Or, visit http://www.medicare.gov on the web.

This document may be available in other formats such as Braille, large print or otheralternate formats.

This document may be available in a non-English language. For additional information,call customer service at the phone number listed above.


Anthem Medicare PreferredCore (PPO)

Original MedicareBenefit

IMPORTANT INFORMATION

General$26 monthly plan premium in addition toyour monthly Medicare Part B premium.

In 2013 the monthly Part B Premium was$104.90 and may change for 2014 and theannual Part B deductible amount was $147and may change for 2014.

1 Premium andOther ImportantInformation

Most people will pay the standard monthlyPart B premium in addition to their MA planIf a doctor or supplier does not accept

assignment, their costs are often higher, whichmeans you pay more.

premium. However, some people will payhigher Part B and Part D premiums becauseof their yearly income (over $85,000 forMost people will pay the standard monthly

Part B premium. However, some people will singles, $170,000 for married couples). Formore information about Part B and Part Dpay a higher premium because of their yearlypremiums based on income, call Medicare atincome (over $85,000 for singles, $170,0001-800-MEDICARE (1-800-633-4227). TTYfor married couples). For more informationusers should call 1-877-486-2048. You mayabout Part B premiums based on income, callalso call Social Security at 1-800-772-1213.TTY users should call 1-800-325-0778.

Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call1-877-486-2048. You may also call Social Some physicians, providers and suppliers that

are out of a plan's network (i.e.,Security at 1-800-772-1213. TTY usersshould call 1-800-325-0778. out-of-network) accept "assignment" from

Medicare and will only charge up to aMedicare-approved amount. If you choose tosee an out-of-network physician who doesNOT accept Medicare "assignment," yourcoinsurance can be based on theMedicare-approved amount plus an additionalamount up to a higher Medicare "limitingcharge." If you are a member of a plan thatcharges a copay for out-of-network physicianservices, the higher Medicare "limiting charge"does not apply. See the publications Medicare& You or Your Medicare Benefits availableon http://www.medicare.gov for a full listingof benefits under Original Medicare, as well

If you have any questions about this plan's benefits or costs, please contactAnthem Blue Cross and Blue Shield for details

Section II:

Summary of Benefits




as for explanations of the rules related to"assignment" and "limiting charges" thatapply by benefit type.

To find out if physicians and DME suppliersaccept assignment or participate in Medicare,visit http://www.medicare.gov/physician orhttp://www.medicare.gov/supplier. You canalso call 1-800-MEDICARE, or ask yourphysician, provider, or supplier if they acceptassignment.

In-Network$4,000 out-of-pocket limit forMedicare-covered services.

In and Out-of-Network$4,000 out-of-pocket limit forMedicare-covered services.

In-NetworkNo referral required for network doctors,specialists, and hospitals.

You may go to any doctor, specialist orhospital that accepts Medicare.

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

In and Out-of-NetworkYou can go to doctors, specialists, andhospitals in or out of the network. It will costmore to get out of network benefits.

Out of Service AreaPlan covers you when you travel in the U.S.or its territories.

SUMMARY OF BENEFITS

Inpatient Care

In-NetworkNo limit to the number of days covered bythe plan each hospital stay.

In 2013 the amounts for each benefit periodwere:

3 InpatientHospital Care(includesSubstance AbuseandRehabilitationServices)

Days 1 - 60: $1,184 deductibleFor Medicare-covered hospital stays:Days 61 - 90: $296 per day

Days 91 - 150: $592 per lifetime reserveday

Days 1 - 6: $265 copay per dayDays 7 - 90: $0 copay per day

These amounts may change for 2014.

1 Premium andOther ImportantInformation(continued)




$0 copay for additional non-Medicare-coveredhospital days

Call 1-800-MEDICARE (1-800-633-4227)for information about lifetime reserve days. Except in an emergency, your doctor must

tell the plan that you are going to be admittedto the hospital.

Lifetime reserve days can only be used once.

A "benefit period" starts the day you go intoa hospital or skilled nursing facility. It ends Out-of-Network

30% of the cost for each Medicare-coveredhospital stay.

when you go for 60 days in a row withouthospital or skilled nursing care. If you go intothe hospital after one benefit period hasended, a new benefit period begins. You mustpay the inpatient hospital deductible for eachbenefit period. There is no limit to thenumber of benefit periods you can have.

In-NetworkYou get up to 190 days of inpatient psychiatrichospital care in a lifetime. Inpatient

In 2013 the amounts for each benefit periodwere:

4 Inpatient MentalHealth Care

Days 1 - 60: $1,184 deductiblepsychiatric hospital services count toward theDays 61 - 90: $296 per day190-day lifetime limitation only if certainDays 91 - 150: $592 per lifetime reserve

day conditions are met. This limitation does notapply to inpatient psychiatric servicesfurnished in a general hospital.These amounts may change for 2014.

For Medicare-covered hospital stays:

You get up to 190 days of inpatient psychiatrichospital care in a lifetime. Inpatient

Days 1 - 6: $205 copay per dayDays 7 - 90: $0 copay per day

psychiatric hospital services count toward thePlan covers 60 lifetime reserve days. $0 copayper lifetime reserve day.

190-day lifetime limitation only if certainconditions are met. This limitation does notapply to inpatient psychiatric servicesfurnished in a general hospital.

Except in an emergency, your doctor musttell the plan that you are going to be admittedto the hospital.

Out-of-Network30% of the cost for each Medicare-coveredhospital stay.

GeneralAuthorization rules may apply.

In 2013 the amounts for each benefit periodafter at least a 3-day Medicare-coveredhospital stay were:

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

In-NetworkPlan covers up to 100 days each benefit period

No prior hospital stay is required.

Days 1 - 20: $0 per dayDays 21 - 100: $148 per day

3 InpatientHospital Care(includesSubstance AbuseandRehabilitationServices)(continued)




These amounts may change for 2014. For SNF stays:

Days 1 - 20: $25 copay per dayDays 21 - 100: $140 copay per day100 days for each benefit period.

Out-of-Network35% of the cost for each Medicare-coveredSNF stay.

A "benefit period" starts the day you go intoa hospital or SNF. It ends when you go for60 days in a row without hospital or skillednursing care. If you go into the hospital afterone benefit period has ended, a new benefitperiod begins. You must pay the inpatienthospital deductible for each benefit period.There is no limit 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 each Medicare-covered homehealth visit

Out-of-Network$0 copay for Medicare-covered home healthvisits

GeneralYou must get care from a Medicare-certifiedhospice. You must consult with your planbefore you select hospice.

You pay part of the cost for outpatient drugsand inpatient respite care.

You must get care from a Medicare-certifiedhospice.

7 Hospice

OUTPATIENT CARE

In-Network$10 copay for each Medicare-covered primarycare doctor visit.

20% coinsurance8 Doctor OfficeVisits

$35 copay for each Medicare-coveredspecialist visit.

Out-of-Network$50 copay for each Medicare-coveredspecialist visit

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




$20 copay for each Medicare-covered primarycare doctor visit


Supplemental routine care not covered

20% coinsurance for manual manipulationof the spine to correct subluxation (a

9 ChiropracticServices

In-Network$20 copay for each Medicare-coveredchiropractic visit

displacement or misalignment of a joint orbody part).

Medicare-covered chiropractic visits are formanual manipulation of the spine to correctsubluxation (a displacement or misalignmentof a joint or body part).

Out-of-Network$50 copay for Medicare-covered chiropracticvisits.

In-Network$35 copay for each Medicare-covered podiatryvisit

Supplemental routine care not covered.

20% coinsurance for medically necessary footcare, including care for medical conditionsaffecting the lower limbs.

10 Podiatry Services

Medicare-covered podiatry visits are formedically necessary foot care.

Out-of-Network$50 copay for Medicare-covered podiatryvisits


20% coinsurance for most outpatient mentalhealth services

11 OutpatientMental HealthCare

In-Network$40 copay for each Medicare-coveredindividual therapy visit

Specified copayment for outpatient partialhospitalization program services furnished bya hospital or community mental health center(CMHC). Copay cannot exceed the Part Ainpatient hospital deductible.

$40 copay for each Medicare-covered grouptherapy visit

"Partial hospitalization program" is astructured program of active outpatient

$40 copay for each Medicare-coveredindividual therapy visit with a psychiatrist

psychiatric treatment that is more intense than$40 copay for each Medicare-covered grouptherapy visit with a psychiatrist

the care received in your doctor's or therapist'soffice and is an alternative to inpatienthospitalization. $40 copay for Medicare-covered partial

hospitalization program services




Out-of-Network$50 copay for Medicare-covered MentalHealth visits with a psychiatrist

$50 copay for Medicare-covered MentalHealth visits

$50 copay for Medicare-covered partialhospitalization program services


20% coinsurance12 OutpatientSubstance AbuseCare

In-Network$40 copay for Medicare-covered individualsubstance abuse outpatient treatment visits

$40 copay for Medicare-covered groupsubstance abuse outpatient treatment visits

Out-of-Network$50 copay for Medicare-covered substanceabuse outpatient treatment visits


20% coinsurance for the doctor's services

Specified copayment for outpatient hospitalfacility services Copay cannot exceed the PartA inpatient hospital deductible.

13 OutpatientServices

In-Network0% to 15% of the cost for eachMedicare-covered ambulatory surgical centervisit

20% coinsurance for ambulatory surgicalcenter facility services

$0 to $35 copay [or 0% to 15% of the cost]for each Medicare-covered outpatient hospitalfacility visit

Out-of-Network30% of the cost for Medicare-coveredambulatory surgical center visits

$20 to $50 copay [or 30% of the cost] forMedicare-covered outpatient hospital facilityvisits

11 OutpatientMental HealthCare(continued)





20% coinsurance14 AmbulanceServices(medicallynecessaryambulanceservices)

In-Network$200 copay for Medicare-covered ambulancebenefits.

If you are admitted to the hospital, you pay$0 for Medicare-covered ambulance benefits.

Out-of-Network$200 copay for Medicare-covered ambulancebenefits.

General$65 copay for Medicare-covered emergencyroom visits

20% coinsurance for the doctor's services

Specified copayment for outpatient hospitalfacility emergency services.

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

Not covered outside the U.S. and its territoriesexcept under limited circumstances. Contactplan for details.

Emergency services copay cannot exceed PartA inpatient hospital deductible for each serviceprovided by the hospital.

You don't have to pay the emergency roomcopay if you are admitted to the hospital asan inpatient for the same condition within 3days of the emergency room visit.

Not covered outside the U.S. except underlimited circumstances.

General$45 copay for Medicare-coveredurgently-needed-care visits

20% coinsurance, or a set copay

If you are admitted to the hospital within 3days for the same condition, you pay $0 forthe urgently-needed-care visit.

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

NOT covered outside the U.S. except underlimited circumstances.


20% coinsurance

Medically necessary physical therapy,occupational therapy, and speech andlanguage pathology services are covered.

17 OutpatientRehabilitationServices(OccupationalTherapy, PhysicalTherapy, Speechand LanguageTherapy)

Medically necessary physical therapy,occupational therapy, and speech andlanguage pathology services are covered.




In-Network$35 copay for Medicare-covered OccupationalTherapy visits

$35 copay for Medicare-covered PhysicalTherapy and/or Speech and LanguagePathology visits

Out-of-Network$50 copay for Medicare-covered PhysicalTherapy and/or Speech and LanguagePathology visits

$50 copay for Medicare-covered OccupationalTherapy visits.

Outpatient Medical Services and Supplies


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

In-Network20% of the cost for Medicare-covered durablemedical equipment

Out-of-Network30% of the cost for Medicare-covered durablemedical equipment


20% coinsurance

20% coinsurance for Medicare-coveredmedical supplies related to prosthetics, splints,and other devices.

19 ProstheticDevices(includes braces,artificial limbsand eyes, etc.)

In-Network20% of the cost for Medicare-coveredprosthetic devices

20% of the cost for Medicare-covered medicalsupplies related to prosthetics, splints, andother devices

Out-of-Network30% of the cost for Medicare-coveredprosthetic devices.


20% coinsurance for diabetesself-management training

20 DiabetesPrograms andSupplies

17 OutpatientRehabilitationServices(OccupationalTherapy, PhysicalTherapy, Speechand LanguageTherapy)(continued)




In-Network$0 copay for Medicare-covered Diabetesself-management training

20% coinsurance for diabetes supplies

20% coinsurance for diabetic therapeuticshoes or inserts

$0 copay for Medicare-covered Diabetesmonitoring supplies

$0 copay for Medicare-covered Therapeuticshoes or inserts

Diabetic Supplies and Services are limited tospecific manufacturers, products and/orbrands. Contact the plan for a list of coveredsupplies.

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

30% of the cost for Medicare-coveredDiabetes monitoring supplies

30% of the cost for Medicare-coveredTherapeutic shoes or inserts


20% coinsurance for diagnostic tests andx-rays

21 Diagnostic Tests,X-Rays, LabServices, andRadiologyServices

In-Network$10 copay for Medicare-covered lab services

$0 to $140 copay for Medicare-covereddiagnostic procedures and tests

$0 copay for Medicare-covered lab services

Lab Services: Medicare covers medicallynecessary diagnostic lab services that areordered by your treating doctor when they areprovided by a Clinical Laboratory $90 copay for Medicare-covered X-raysImprovement Amendments (CLIA) certified

$90 to $140 copay for Medicare-covereddiagnostic radiology services (not includingX-rays)

laboratory that participates in Medicare.Diagnostic lab services are done to help yourdoctor diagnose or rule out a suspected illnessor condition. Medicare does not cover most 20% of the cost for Medicare-covered

therapeutic radiology servicessupplemental routine screening tests, likechecking your cholesterol.

If the doctor provides you services in additionto Outpatient Diagnostic Procedures, Testsand Lab Services, separate cost sharing of $10to $35 may apply

If the doctor provides you services in additionto Outpatient Diagnostic and Therapeutic

20 DiabetesPrograms andSupplies(continued)




Radiology Services, separate cost sharing of$10 to $35 may apply

Out-of-Network35% of the cost for Medicare-coveredoutpatient X-rays

35% of the cost for Medicare-covereddiagnostic radiology services

35% of the cost for Medicare-covereddiagnostic procedures and tests

$20 copay for Medicare-covered lab services

20% of the cost for Medicare-coveredtherapeutic radiology services

In-Network$35 copay for Medicare-covered CardiacRehabilitation Services

20% coinsurance for Cardiac Rehabilitationservices

20% coinsurance for PulmonaryRehabilitation services

22 Cardiac andPulmonaryRehabilitationServices

$35 copay for Medicare-covered IntensiveCardiac Rehabilitation Services20% coinsurance for Intensive Cardiac

Rehabilitation services $35 copay for Medicare-covered PulmonaryRehabilitation Services

Out-of-Network$50 copay for Medicare-covered CardiacRehabilitation Services

$50 copay for Medicare-covered IntensiveCardiac Rehabilitation Services

$50 copay for Medicare-covered PulmonaryRehabilitation Services

PREVENTIVE SERVICES

General$0 copay for all preventive services coveredunder Original Medicare at zero cost sharing.

No coinsurance, copayment or deductible forthe following:

23 PreventiveServices

Abdominal Aortic Aneurysm ScreeningAny additional preventive services approvedby Medicare mid-year will be covered by theplan or by Original Medicare.

Bone Mass Measurement. Covered onceevery 24 months (more often if medicallynecessary) if you meet certain medicalconditions.

21 Diagnostic Tests,X-Rays, LabServices, andRadiologyServices(continued)




Out-of-Network$0 to $50 copay for Medicare-coveredpreventive services

Cardiovascular ScreeningCervical and Vaginal Cancer Screening.Covered once every 2 years. Covered oncea year for women with Medicare at highrisk.Colorectal Cancer ScreeningDiabetes ScreeningInfluenza VaccineHepatitis B Vaccine for people withMedicare who are at riskHIV Screening. $0 copay for the HIVscreening, but you generally pay 20% ofthe Medicare-approved amount for thedoctor's visit. HIV screening is covered forpeople with Medicare who are pregnantand people at increased risk for theinfection, including anyone who asks forthe test. Medicare covers this test onceevery 12 months or up to three timesduring a pregnancy.Breast Cancer Screening (Mammogram).Medicare covers screening mammogramsonce every 12 months for all women withMedicare age 40 and older. Medicarecovers one baseline mammogram forwomen between ages 35-39.Medical Nutrition Therapy ServicesNutrition therapy is for people who havediabetes or kidney disease (but aren't ondialysis or haven't had a kidney transplant)when referred by a doctor. These servicescan be given by a registered dietitian andmay include a nutritional assessment andcounseling to help you manage yourdiabetes or kidney diseasePersonalized Prevention Plan Services(Annual Wellness Visits)Pneumococcal Vaccine. You may onlyneed the Pneumonia vaccine once in yourlifetime. Call your doctor for moreinformation.Prostate Cancer Screening

23 PreventiveServices(continued)




Prostate Specific Antigen (PSA) test only.Covered once a year for all men withMedicare over age 50.Smoking and Tobacco Use Cessation(counseling to stop smoking and tobaccouse). Covered if ordered by your doctor.Includes two counseling attempts withina 12-month period. Each counselingattempt includes up to four face-to-facevisits.Screening and behavioral counselinginterventions in primary care to reducealcohol misuseScreening for depression in adultsScreening for sexually transmittedinfections (STI) and high-intensitybehavioral counseling to prevent STIsIntensive behavioral counseling forCardiovascular Disease (bi-annual)Intensive behavioral therapy for obesityWelcome to Medicare Preventive Visits(initial preventive physical exam) Whenyou join Medicare Part B, then you areeligible as follows. During the first 12months of your new Part B coverage, youcan get either a Welcome to MedicarePreventive Visits or an Annual WellnessVisit. After your first 12 months, you canget one Annual Wellness Visit every 12months.

In-Network20% of the cost for Medicare-covered renaldialysis

20% coinsurance for renal dialysis

20% coinsurance for kidney disease educationservices

24 Kidney Diseaseand Conditions

$0 copay for Medicare-covered kidney diseaseeducation services

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

20% of the cost for Medicare-covered renaldialysis

23 PreventiveServices(continued)




PRESCRIPTION DRUG BENEFITS

Drugs Covered Under Medicare Part BGeneral20% of the cost for Medicare Part Bchemotherapy drugs and other Part B drugs.

Most drugs are not covered under OriginalMedicare. You can add prescription drugcoverage to Original Medicare by joining aMedicare Prescription Drug Plan, or you canget all your Medicare coverage, including

25 OutpatientPrescriptionDrugs

30% of the cost for Medicare Part B drugsout-of-network.prescription drug coverage, by joining a

Medicare Advantage Plan or a Medicare CostPlan that offers prescription drug coverage. Drugs Covered Under Medicare Part D

GeneralThis plan uses a formulary. The plan will sendyou the formulary. You can also see theformulary at http://www.anthem.com/medicare on the web.

Different out-of-pocket costs may apply forpeople who

have limited incomes,live in long term care facilities, orhave access to Indian/Tribal/Urban (IndianHealth Service) providers.

The plan offers national in-networkprescription coverage (i.e., this would include50 states and the District of Columbia). Thismeans that you will pay the same cost-sharingamount for your prescription drugs if you getthem at an in-network pharmacy outside ofthe plan's service area (for instance when youtravel).

Total yearly drug costs are the total drug costspaid by both you and a Part D plan.

The plan may require you to first try one drugto treat your condition before it will coveranother drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorizationfrom Anthem Medicare Preferred Core (PPO)for certain drugs.




You must go to certain pharmacies for a verylimited number of drugs, due to specialhandling, provider coordination, or patienteducation requirements that cannot be metby most pharmacies in your network. Thesedrugs are listed on the plan's website,formulary, printed materials, as well as on theMedicare Prescription Drug Plan Finder onMedicare.gov.

If the actual cost of a drug is less than thenormal cost-sharing amount for that drug,you will pay the actual cost, not the highercost-sharing amount.

If you request a formulary exception for a drugand Anthem Medicare Preferred Core (PPO)approves the exception, you will pay Tier 4:Non-Preferred Brand cost sharing for thatdrug.

In-Network$60 deductible on all drugs except Tier 1:Preferred Generic, Tier 2: Non-PreferredGeneric, Tier 5: Injectable Drugs, Tier 6:Specialty Tier drugs.

Initial CoverageAfter you pay your yearly deductible, you paythe following until total yearly drug costsreach $2,850:

Retail PharmacyContact your plan if you have questions aboutcost-sharing or billing when less than aone-month supply is dispensed.

You can get drugs from a preferred andnon-preferred pharmacy the following way(s):

Tier 1: Preferred Generic$1 copay for a one-month (30-day) supplyof drugs in this tier from a preferredpharmacy

25 OutpatientPrescriptionDrugs(continued)




$2 copay for a two-month (60-day) supplyof drugs in this tier from a preferredpharmacy$3 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$6 copay for a one-month (30-day) supplyof drugs in this tier from a non-preferredpharmacy$12 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$18 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy

Tier 2: Non-Preferred Generic$7 copay for a one-month (30-day) supplyof drugs in this tier from a preferredpharmacy$14 copay for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy$21 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$12 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred pharmacy$24 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$36 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy

Tier 3: Preferred Brand$40 copay for a one-month (30-day)supply of drugs in this tier from a preferredpharmacy$80 copay for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy





$120 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$45 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred pharmacy$90 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$135 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy

Tier 4: Non-Preferred Brand$90 copay for a one-month (30-day)supply of drugs in this tier from a preferredpharmacy$180 copay for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy$270 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$95 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred pharmacy$190 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$285 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy

Tier 5: Injectable Drugs33% coinsurance for a one-month(30-day) supply of drugs in this tier froma preferred pharmacy33% coinsurance for a two-month(60-day) supply of drugs in this tier froma preferred pharmacy33% coinsurance for a three-month(90-day) supply of drugs in this tier froma preferred pharmacy





33% coinsurance for a one-month(30-day) supply of drugs in this tier froma non-preferred pharmacy33% coinsurance for a two-month(60-day) supply of drugs in this tier froma non-preferred pharmacy33% coinsurance for a three-month(90-day) supply of drugs in this tier froma non-preferred pharmacy

Tier 6: Specialty Tier33% coinsurance for a one-month(30-day) supply of drugs in this tier froma preferred pharmacy33% coinsurance for a one-month(30-day) supply of drugs in this tier froma non-preferred pharmacy

Long-Term Care PharmacyLong term care pharmacies must dispensebrand name drugs in amounts less than a 14days supply at a time. They may also dispenseless than a month's supply of generic drugs ata time. Contact your plan if you havequestions about cost-sharing or billing whenless than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic$6 copay for a one-month (34-day) supplyof drugs in this tier

Tier 2: Non-Preferred Generic$12 copay for a one-month (34-day)supply of drugs in this tier

Tier 3: Preferred Brand$45 copay for a one-month (34-day)supply of drugs in this tier





Tier 4: Non-Preferred Brand$95 copay for a one-month (34-day)supply of drugs in this tier

Tier 5: Injectable Drugs33% coinsurance for a one-month(34-day) supply of drugs in this tier

Tier 6: Specialty Tier33% coinsurance for a one-month(34-day) supply of drugs in this tier

Mail OrderContact your plan if you have questions aboutcost-sharing or billing when less than aone-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Preferred Generic$1 copay for a one-month (30-day) supplyof drugs in this tier$2 copay for a two-month (60-day) supplyof drugs in this tier$2 copay for a three-month (90-day)supply of drugs in this tier

Tier 2: Non-Preferred Generic$7 copay for a one-month (30-day) supplyof drugs in this tier$14 copay for a two-month (60-day)supply of drugs in this tier$14 copay for a three-month (90-day)supply of drugs in this tier

Tier 3: Preferred Brand$40 copay for a one-month (30-day)supply of drugs in this tier$120 copay for a two-month (60-day)supply of drugs in this tier$120 copay for a three-month (90-day)supply of drugs in this tier





Tier 4: Non-Preferred Brand$90 copay for a one-month (30-day)supply of drugs in this tier$270 copay for a two-month (60-day)supply of drugs in this tier$270 copay for a three-month (90-day)supply of drugs in this tier

Tier 5: Injectable Drugs33% coinsurance for a one-month(30-day) supply of drugs in this tier33% coinsurance for a two-month(60-day) supply of drugs in this tier33% coinsurance for a three-month(90-day) supply of drugs in this tier


Coverage GapAfter your total yearly drug costs reach$2,850, you receive limited coverage by theplan on certain drugs. You will also receive adiscount on brand name drugs and generallypay no more than 47.5% for the plan's costsfor brand drugs and 72% of the plan's costsfor generic drugs until your yearlyout-of-pocket drug costs reach $4,550.

Catastrophic CoverageAfter your yearly out-of-pocket drug costsreach $4,550, you pay the greater of:

5% coinsurance, or$2.55 copay for generic (including branddrugs treated as generic) and a $6.35 copayfor all other drugs.

Out-of-NetworkPlan drugs may be covered in specialcircumstances, for instance, illness whiletraveling outside of the plan's service area





where there is no network pharmacy. You mayhave to pay more than your normalcost-sharing amount if you get your drugs atan out-of-network pharmacy. In addition, youwill likely have to pay the pharmacy's fullcharge for the drug and submitdocumentation to receive reimbursement fromAnthem Medicare Preferred Core (PPO).

You can get out-of-network drugs thefollowing way:

Out-of-Network Initial CoverageAfter you pay your yearly deductible, you willbe reimbursed up to the plan's cost of the drugminus the following for drugs purchasedout-of-network until your total yearly drugcosts reach $2,850:

Tier 1: Preferred Generic$6 copay for a one-month (30-day) supplyof drugs in this tier

Tier 2: Non-Preferred Generic$12 copay for a one-month (30-day)supply of drugs in this tier

Tier 3: Preferred Brand$45 copay for a one-month (30-day)supply of drugs in this tier

Tier 4: Non-Preferred Brand$95 copay for a one-month (30-day)supply of drugs in this tier

Tier 5: Injectable Drugs33% coinsurance for a one-month(30-day) supply of drugs in this tier






You will not be reimbursed for the differencebetween the Out-of-Network Pharmacycharge and the plan's In-Network allowableamount.

Out-of-Network Coverage GapYou will be reimbursed up to 28% of the planallowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocketdrug costs reach $4,550. Please note that theplan allowable cost may be less than theout-of-network pharmacy price paid for yourdrug(s).

You will be reimbursed up to 52.5% of theplan allowable cost for brand name drugspurchased out-of-network until your totalyearly out-of-pocket drug costs reach $4,550.Please note that the plan allowable cost maybe less than the out-of-network pharmacyprice paid for your drug(s).

Out-of-Network Catastrophic CoverageAfter your yearly out-of-pocket drug costsreach $4,550, you will be reimbursed fordrugs purchased out-of-network up to theplan's cost of the drug minus your cost share,which is the greater of:

5% coinsurance, or$2.55 copay for generic (including branddrugs treated as generic) and a $6.35 copayfor all other drugs.

You will not be reimbursed for the differencebetween the Out-of-Network Pharmacycharge and the plan's In-Network allowableamount.





Outpatient Medical Services and Supplies

In-NetworkThis plan covers some preventive dentalbenefits for an extra cost (see "OptionalSupplemental Benefits.")

Preventive dental services (such as cleaning)not covered.

26 Dental Services

$0 copay for Medicare-covered dental benefits

Out-of-Network$0 copay for Medicare-covered comprehensivedental benefits

In-NetworkIn general, supplemental routine hearingexams and hearing aids not covered.

Supplemental routine hearing exams andhearing aids not covered.

20% coinsurance for diagnostic hearingexams.

27 Hearing Services

$35 copay for Medicare-covered diagnostichearing exams

Out-of-Network$50 copay for Medicare-covered diagnostichearing exams.

In-NetworkThis plan covers some vision benefits for anextra cost (see "Optional SupplementalBenefits").

20% coinsurance for diagnosis and treatmentof diseases and conditions of the eye,including an annual glaucoma screening forpeople at risk

28 Vision Services

$0 to $35 copay for Medicare-covered examsto diagnose and treat diseases and conditions

Supplemental routine eye exams and eyeglasses(lenses and frames) not covered.

of the eye, including an annual glaucomascreening for people at risk

Medicare pays for one pair of eyeglasses orcontact lenses after cataract surgery.

$35 copay for one pair of Medicare-coveredeyeglasses (lenses and frames) or contact lensesafter cataract surgery.

Out-of-Network$50 copay for Medicare-covered eyewear

$0 to $50 copay for Medicare-covered eyeexams

In-NetworkThe plan covers the following supplementaleducation/wellness programs:

Not covered.Wellness/Educationand Other




SupplementalBenefits & Services

Health Club Membership/Fitness ClassesNursing Hotline

Out-of-Network$0 copay for supplemental education/wellnessprograms

GeneralThe plan does not cover Over-the-Counteritems.

Not covered.Over-the-CounterItems

In-NetworkThis plan does not cover supplemental routinetransportation.

Not covered.Transportation(Routine)

In-NetworkThis plan does not cover Acupuncture andother alternative therapies.

Not covered.Acupuncture andOther AlternativeTherapies

OPTIONAL SUPPLEMENTAL PACKAGE #1

GeneralPackage: 1 - Preventive Dental Package:

Premium and OtherImportantInformation

$18 monthly premium, in addition to your$26 monthly plan premium and the monthlyMedicare Part B premium, for the followingoptional benefits:

Preventive Dental

In-Network$0 copay for up to 2 supplemental oralexam(s) every year

Dental Services

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

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

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




In and Out-of-Network$500 plan coverage limit for supplementalpreventive dental benefits every year. Thislimit applies to both in-network andout-of-network benefits.


GeneralPackage: 2 - Dental and Vision Package:



Preventive DentalComprehensive DentalEye ExamsEyewear


Dental Services




30% to 75% of the cost for supplementalcomprehensive dental services

In and Out-of-NetworkContact the plan for availability of additionalsupplemental in-network and out-of-networkcomprehensive dental benefits.

$1,000 plan coverage limit for supplementaldental benefits every year. This limit appliesto both in-network and out-of-networkbenefits.

Dental Services(continued)




In-Network$0 copay for up to 1 pair(s) of contact lensesevery year

Vision Services

$0 copay for up to 1 pair(s) of eyeglasses(lenses and frames) every year

$0 copay for up to 1 supplemental routineeye exam(s) every year

Out-of-Network$0 copay for supplemental routine eye exams

$0 copay for supplemental eyewear

In and Out-of-Network$69 plan coverage limit for supplementalroutine eye exams every year. This limitapplies to both in-network andout-of-network benefits.

$130 plan coverage limit for eyeglasses (lensesand frames) every year. This limit applies toboth in-network and out-of-network benefits.

$80 plan coverage limit for contact lensesevery year. This limit applies to bothin-network and out-of-network benefits.


GeneralPackage: 3 - Enhanced Dental and VisionPackage:



Preventive DentalComprehensive DentalEye ExamsEyewear





Dental Services




30% to 75% of the cost for supplementalcomprehensive dental services

In and Out-of-NetworkContact the plan for availability of additionalsupplemental in-network and out-of-networkcomprehensive dental benefits.

$1,500 plan coverage limit for supplementaldental benefits every year. This limit appliesto both in-network and out-of-networkbenefits.

In-Network$0 copay for up to 1 pair(s) of contact lensesevery year

Vision Services

$0 copay for up to 1 pair(s) of eyeglasses(lenses and frames) every year

$0 copay for up to 1 supplemental routineeye exam(s) every year

Out-of-Network$0 copay for supplemental routine eye exams

$0 copay for supplemental eyewear

In and Out-of-Network$69 plan coverage limit for supplementalroutine eye exams every year. This limitapplies to both in-network andout-of-network benefits.




$200 plan coverage limit for eyeglasses (lensesand frames) every year. This limit applies toboth in-network and out-of-network benefits.

$80 plan coverage limit for contact lensesevery year. This limit applies to bothin-network and out-of-network benefits.

Vision Services(continued)


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