Medicare Supplement Outline of Coverage...Medicare Supplement Outline of Coverage Plans A, F,...

Medicare Supplement Outline of CoveragePlans A, F, Innovative F, G & N

Anthem Blue Cross

California 2020

This booklet includes premium rates, Medicare deductibles,

copays and maximum out-of-pocket costs.

Call toll-free 1-800-333-3883 with questions.

Administrative Office: P.O. Box 659816, San Antonio, TX 78265-9116

AOOC002M(Rev. 2/19)-CA

OOC_MS_CA-IB_AOOC002M-191024-MACRA-2020rates-2019mnocs October 24, 2019 3:23 PM

2020 Outline of Medicare Supplement Coverage 1

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of $2,300 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. We do not offer High Deductible Plans F or G.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment

for emergency room visits that do not result in an inpatient admission. 4 Innovative F includes additional benefits not contained in other standardized Medicare Supplement Plans as outlined in the

following pages.

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after January 1, 2020

A B D G1 K L M N

Medicare Part A coinsurance andhospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment

50 % 75 % copays apply3

Blood (first three pints) 50 % 75 %

Part A hospice care coinsurance or copayment

50 % 75 %

Skilled nursing facility coinsurance 50 % 75 %

Medicare Part A deductible 50 % 75 % 50 %

Medicare Part B deductible

Medicare Part B excess charges

Foreign travel emergency (up to plan limits)

Out-of-pocket limit in 20192 $5,5602 $2,7802

Plans Available to All Applicants

C F1, 4

1,4

Medicare first eligible before 2020 only

This chart shows the benefits included in each of the standard Medicare Supplement plans.

Every company must make Plan “A” available. Some plans may not be available. Only applicants first eligible for Medicare

before 2020 may purchase Plans C, F and high deductible F.

Plans shown in gray are available for purchase. These same plans are available to those who are under 65 and qualify

for Medicare due to disability (except those that qualify due to ESRD).

Note: A “ ” means 100% of the benefit is paid.

Benefits


Finding Your Monthly Premium

Plans A, F, Innovative F, G & N | Effective March 1, 2020 Premiums are subject to change.

Here’s some important information, before we get started:

We, Anthem Blue Cross, can only raise your premium if we raise the premium for all plans like yours in this State. We will recalculate your age each year and adjust your premium based on the new age band in March of each year up to the age cap.

Premiums are subject to change on or after the Renewal Date in accordance with the terms of the Policy. Renewal Date is defined as March 1, subject to state approval. The selected billing preference does not guarantee your premium for any specific period. Approved premium changes are effective as of the Renewal Date.

If you select a billing method other than Monthly EFT (Electronic Fund Transfer), the billing frequency takes effect on the first day of the payment period that immediately follows your coverage effective date. Based on your selected billing method and your coverage effective date, we will prorate the initial premium to align you with the quarterly or annual billing. For example, if you select quarterly billing and your coverage effective date is September 1, your quarterly billing will start on October 1. We base annual billing on a calendar year (January-December).

Find Your Premium

Premiums (and future changes to premiums) are determined by several factors, including whether you are applying during your Open Enrollment Period, are eligible for Guaranteed Issue coverage, the county and/or zip code where you live, tobacco use, age, plan, and the costs of medical services and supplies.

Your Open Enrollment period is the best time to buy a Medicare Supplement plan. The Open Enrollment period automatically starts the month you turn age 65 and enroll in Medicare Part B — this period only occurs once and allows you to enroll in any plan offered. During this period, you do not go through medical underwriting and are guaranteed acceptance into the Plan of your choice!

When outside your Open Enrollment period you may experience a Guaranteed Issue right. These rights generally occur when you have other health coverage that changes. In California, you have this period annually based on your birthday. During this period, your Medicare Supplement plan options may be limited.

Here’s how to find your premium, step-by-step:

Premium Information Finding the Right Plan for YouPremium Information

STEP 2:

Determine Which Premium

Table Applies to You

STEP 1:

Determine Your

Rating Area

Find Your

Premium

NOW … You Are

Ready to Compare

Plan Premiums

Tobacco / Non-Tobacco




Compare Plans

After locating the monthly premium, you are ready to review the individual plan pages. These pages

provide details of the covered services and what each plan pays. Based on your individual needs,

these pages will help you determine the plan that is best for you. You are now ready to ENROLL!

Premium Information Finding the Right Plan for YouFinding the Right Plan for You

Don’t miss out on a chance to SAVE!

These optional discounts are offered.

* By calling this number, you will reach an authorized licensed insurance agent who can answer questions about our plans and enrollment.

Ways to Enroll

Sales Department*

Call 1-888-211-9813

(TTY/TDD: 711)

8 a.m. to 8 p.m.,

seven days a week

(except Thanksgiving

and Christmas) from

October 1 through

March 31, and Monday

to Friday (except holidays)

from April 1 through

September 30

Let’s Begin

Customer Service

Call 1-800-333-3883

(TTY/TDD: 711)

8 a.m. to 6 p.m. PT

Monday - Friday

Visit us Online

www.anthem.com/ca

- Enroll online

- Find a doctor

- Find a pharmacy

- List of covered drugs

SAVE $2 on your monthly premium!

Enroll in our Automatic Bank Draft or Electronic Fund Transfer (EFT) program and you will save $2 on your monthly premium. (To enroll, simply complete the Premium Payment Form.)

SAVE $48 by paying your premium for the entire year!

(Note: Based on the policy effective date, the discount may be pro-rated the first year.)

SAVE 5% when more than one member in the household enrolls in a Medicare Supplement

plan with us. The discount is for policies with effective dates of June 1, 2010 or after and

available to those members who occupy the same housing unit.

OR

New to Medicare — Enroll in Plan F or Innovative F and SAVE $240!

If you are age 65 or older, and within six months of your Part B effective date you will receive

$20 off your monthly premium for the first 12 months of your policy. This discount is applicable

to Plan F policies with an effective date of March 1, 2016 or after.




Step 1: Determine Your Rating Area County Area Guide

◊ This county spans multiple rating areas.

(continued)

Find the county you live in

from the list below.

Got Your Rating Area?

Now you are ready to go to Step #2.

County Area

Los Angeles◊

(For this county, use your zip code to find your area.)

90001-90084 5

90086-90089

90091

90093-90096

90099

90101-90103

90189

90201

90202

90209-90213

90220-90224

90230-90233

90239-90242

90245

90247-90251

90254

90255

County Area

90260-90267 5

90270

90272

90274

90275

90277

90278

90280

90290-90296

90301-90313

90397

90398

90401-90411

90501-90510

90601-90610

90612

90623

90630

90631

90637-90640

County Area

90650-90652 5

90659-90662

90670

90671

90701-90704

90706

90707

90710-90717

90723

90731-90734

90744-90749

90755

90801-90810

90813-90815

90822

90831-90835

90840

90842

90844-90848

County Area

Alameda 3

Alpine 1

Amador 1

Butte 1

Calaveras 1

Colusa 1

Contra Costa 3

Del Norte 1

El Dorado 1

Fresno 2

Glenn 1

Humboldt 1

Imperial 2

Inyo 1

Kern 2

Kings 1

Lake 1

Lassen 1

(see next page for more counties)






(continued)





County Area

Los Angeles◊

(Contined — For this county, use your zip code to find your area.)

90853 5

90888

90895

90899

91001

91003

91006-91012

91016

91017

91020

91021

91023-91025

91030

91031

91040-91043

91046

91066

91077

County Area

91101-91110 5

91114-91118

91121

91123-91126

91129

91131

91182

91184

91185

91188

91189

91191

91199

91201-91210

91214

91221

91222

91224-91226

91301-91311

91313

91316

91321

County Area

91322 5

91324-91331

91333-91335

91337

91340-91346

91350-91357

91361

91362

91363-91365

91367

91371

91372

91376

91380-91388

91390

91392-91396

91399

91401-91413

91416

91423

91426

County Area

91436 5

91470

91482

91495-91497

91499

91501-91508

91510

91521-91523

91526

91601-91612

91614-91618

91702 6

91706

91709 5

91711

91714-91716 6

91722-91724

91731-91735

91740

91741 5

91744-91749 6







(continued)





County Area

Madera 2

Marin 3

Mariposa 2

Mendocino 1

Merced 2

Modoc 1

Mono 1

Monterey 1

Napa 2

Nevada 1

Orange 4

County Area

Placer 1

Plumas 1

Riverside 6

Sacramento 2

San Benito 1

San Bernardino 6

San Diego 6

San Francisco 3

San Joaquin 2

San Luis Obispo 2

San Mateo 3

County Area

Los Angeles◊

(Contined — For this county, use your zip code to find your area.)

91750 5

91754-91756 6

91759 5

91765 6

91766 5

91767-91769

91770-91772 6

91773 5

91775 6

91776

91778

91780

91788-91793

91795

91797 5

91799 6

County Area

91801-91804 5

91841

91896

91899

93243

93510 6

93532

93534-93536

93539

93543

93544

93550-93553

93560 5

93563 6

93584

93586

93590

93591

93599 5







(continued)





County Area

Santa Clara 3

Santa Cruz 2

Shasta 1

Sierra 1

Siskiyou 1

Solano 2

Sonoma 2

Stanislaus 2

Sutter 1

Tehama 1

Trinity 1

Tulare 1

Tuolumne 1

Ventura 6

Yolo 1

Yuba 1

County Area

Santa Barbara◊

(For this county, use your zip code to find your area.)

93013 3

93014 2

93067

93101-93103

93105-93111

93116-93118

93120

93121

93130

93140

93150

93160

County Area

93190 2

93199

93252 3

93254 2

93427

93429

93434

93436-93438

93440

93441

93454-93458

93460

93463

93464




(see next page for more areas)

Premium is based upon your tobacco usage, age, area and plan.

Step 2: Find Your Premium (continued)

Use this table if: you are in your Open Enrollment Period, or are eligible for Guaranteed Issue;

—or— you do not use tobacco products. (Tobacco users should use Table 2.)

Table 1 | Non-Tobacco Users and/or Open Enrollment or Guaranteed Issue

*Attained age at the time of enrollment.**Plan G is available to those under 65 and newly eligible for Medicare as of January 1, 2020.

Areas 1, 2 and 3

Ag

e*

Plan

A Pl

an

F In

nova

tive

F Pl

an

G Pl

an

N

<65** $234.44 $492.07 $468.83 $376.47 $304.41

65 99.76 183.01 156.74 125.49 127.65

66 103.81 190.46 163.74 130.58 132.82

67 107.99 198.15 170.97 135.86 138.19

68 112.34 206.11 178 .47 141.31 143.75

69 116.84 214.37 186.23 147. 0 0 149.51

70 121.51 222.96 194.30 152.87 155.49

71 126.36 231.83 202.66 158.97 161.69

72 131.38 241.05 211.33 165.26 168.10

73 136.59 250.61 220.32 171.83 174 .78

74 141.99 260.52 229.64 178.63 181.69

75 147.58 270.78 239.29 185.66 188.85

76 153.40 281.44 249.31 192.96 196.28

77 159.41 292.46 259.68 200.54 203.98

78 165.65 303.92 270.46 208.40 211.97

79 172.13 315.81 281.64 216.52 220.25

80 178.83 328.11 293.20 224.97 228.83

81+ 185.99 341.24 305.55 233.97 237.98



Plans A, F, Innovative F, G & N | Effective March 1, 2020 Premiums are subject to change. Premium is based upon your tobacco usage, age, area and plan.






Areas 4 and 5

Ag

e*

Plan

A Pl

an

F In

nova

tive

F Pl

an

G Pl

an

N

<65** $325.84 $642.20 $611.88 $454.89 $423.08

65 126.17 215.59 189.18 151.63 154.24

66 131.29 224.36 197.68 157.78 160.49

67 136.58 233.42 206.46 164.16 166.98

68 142.08 242.80 215.56 170.75 173.69

69 147.77 252.53 224.98 177. 6 2 180.66

70 153.68 262.65 234.78 184 .71 187. 8 8

71 159.81 273.10 244.92 192.08 195.37

72 166.16 283.96 255.45 199.69 203.12

73 172.75 295.22 266.36 207.63 211.19

74 179.58 306.89 277.67 215.84 219.54

75 186.65 318.98 289.39 224.33 228.19

76 194.01 331.54 301.55 233.16 2 37.17

77 201.61 344.52 314.15 242.31 246.47

78 209.50 358.02 327.24 251.81 256.13

79 217.69 372.02 340.81 261.63 266.13

80 226.17 386.51 354.85 271.83 276.50

81+ 235.22 401.98 369.84 282.71 287.56





(see next page for Table 2)







Area 6

Ag

e*

Plan

A Pl

an

F In

nova

tive

F Pl

an

G Pl

an

N

<65** $307.95 $542.11 $516.52 $402.08 $325.09

65 119.24 196.94 169.84 134.03 136.33

66 124.08 204.95 177. 37 139.46 141.86

67 129.08 213.23 185.15 145.10 147. 59

68 134.28 221.79 193.22 150.93 153.52

69 139.66 230.68 201.57 157.00 159.69

70 145.24 239.93 210.26 163.27 166.07

71 151.04 249.47 219.25 169.78 172.69

72 157.04 259.39 228.58 176.51 179.54

73 163.27 269.68 238.25 183.52 186.67

74 169.72 280.35 248.29 190.78 194.05

75 176.40 291.39 258.66 198.29 201.70

76 183.36 302.86 269.45 206.09 209.63

77 190.54 314.72 280.62 214.18 217. 85

78 198.00 327.05 292.21 222.57 226.39

79 205.74 339.84 304.25 231.25 235.23

80 213.75 353.08 316.69 240.27 244.40

81+ 222.31 367.21 329.97 249.89 254.17






Use this table if: you have used tobacco products in the past 12 months. (If you are not a tobacco

user, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table 1.)

Table 2 | For Tobacco Users



Ag

e*

Plan

A Pl

an

F In

nova

tive

F Pl

an

G Pl

an

N

<65** $262.57 $551.12 $525.09 $421.64 $340.93

65 111.73 204.97 175.55 140.55 142.97

66 116.27 213.32 183.39 146.25 148.76

67 120.95 221.93 191.49 152.16 154.78

68 125.82 230.84 199.89 158.27 161.00

69 130.86 240.09 208.58 164.64 167.4 6

70 136.10 249.72 217.62 171.21 174 .15

71 141.53 259.65 226.98 178.04 181.09

72 147.15 269.98 236.69 185.10 188.27

73 152.98 280.68 246.76 192.45 195.75

74 159.03 291.78 257.20 200.06 203.49

75 165.29 303.27 268.00 207.93 211.51

76 171.81 315.21 279.23 216.12 219.84

77 178.54 327.56 290.84 224.60 228.46

78 185.53 340.39 302.92 233.41 2 37.41

79 192.78 353.71 315.44 242.51 246.68

80 200.29 367.48 328.38 251.96 256.29

81+ 208.31 382.19 342.22 262.05 266.54

Areas 1, 2 and 3










Ag

e*

Plan

A Pl

an

F In

nova

tive

F Pl

an

G Pl

an

N

<65** $364.94 $719.26 $685.31 $509.48 $473.85

65 141.31 241.46 211.88 169.83 172.75

66 147.04 251.29 221.40 176 .71 179.75

67 152.97 261.43 231.24 183.86 187. 0 2

68 159.13 271.93 241.43 191.24 194.53

69 165.50 282.83 251.98 198.93 202.34

70 172.12 294.16 262.95 206.88 210.43

71 178.99 305.87 274.31 215.13 218.81

72 186.10 318.03 286.10 223.65 227.49

73 193.48 330.64 298.32 232.55 236.53

74 201.13 343.72 310.99 241.74 245.88

75 209.05 357.26 324.12 251.25 255.57

76 217.29 371.32 3 37.74 261.14 265.63

77 225.80 385.86 351.85 271.39 276.05

78 234.64 400.98 366.51 282.03 286.87

79 243.81 416.67 381.71 293.03 298.07

80 253.31 432.90 397.43 304.45 309.68

81+ 263.45 450.22 414.22 316.64 322.07

Areas 4 and 5











Ag

e*

Plan

A Pl

an

F In

nova

tive

F Pl

an

G Pl

an

N

<65** $344.91 $ 6 07.17 $578.50 $450.33 $364.11

65 133.55 220.57 190.22 150.11 152.69

66 138.97 229.55 198.65 156.20 158.88

67 144.57 238.82 207.37 162.51 165.30

68 150.39 248.41 216.41 169.04 171.95

69 156.42 258.37 225.76 175.84 178.85

70 162.67 268.72 235.49 182.86 186.00

71 169.16 279.41 245.56 190.15 193.41

72 175.88 290.52 256.01 197. 6 9 201.08

73 182.86 302.04 266.84 205.55 209.07

74 190.09 313.99 278.08 213.67 217.34

75 197.57 326.35 289.70 222.08 225.90

76 205.36 339.20 301.78 230.82 234.79

77 213.41 352.48 314.29 239.88 244.00

78 221.76 366.29 327.28 249.28 253.56

79 230.43 380.62 340.76 259.01 263.46

80 239.40 395.45 354.69 269.10 273.73

81+ 248.98 411.27 369.57 279.87 284.68

Area 6


Important Plan Disclosures

Plans A, F, Innovative F, G & N Retain this outline for your records.

Disclosures

Use this outline to compare benefits and

premiums among policies.

Medicare deductibles and coinsurance

amounts are effective as of January 1, 2019.

Medicare may change their amounts annually.

Read Your Policy Very Carefully

This is only an outline describing your policy’s

most important features. The policy is your

insurance contract. You must read the policy

itself to understand all of the rights and duties

of both you and Anthem Blue Cross.

Right to Return Policy

If you find that you are not satisfied with

your policy, you may return it to us at our

Administrative Office: P.O. Box 659816, San

Antonio, TX 78265-9116. If you send the policy

back to us within 30 days after you receive it,

we will treat the policy as if it had never been

issued and return all of your payments.

Policy Replacement

If you are replacing another health insurance

policy, do NOT cancel it until you have actually

received your new policy and are sure you

want to keep it.

Notice

This policy may not fully cover all of your

medical costs.

Neither Anthem Blue Cross nor its agents are

connected with Medicare.

This outline of coverage does not give all

the details of Medicare coverage. Contact

your local Social Security Office or consult

Medicare and You for more details.

Complete Answers are Very Important

When you fill out the application for the

new policy, be sure to answer truthfully and

completely all questions about your

medical and health history. The company

may cancel your policy and refuse to pay any

claims if you leave out or falsify important

medical information.

Review the application carefully before you

sign it. Be certain that all information has

been properly recorded.

(continued)

Medicare (Part A) – Hospital Services – Per Benefit Period

Plan A

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Services Medicare Pays Plan Pays You Pay

Hospitalization*Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,364 $0$1,364 (Part A deductible)

61st thru 90th day All but $341 a day $341 a day $0

91st day and after: While using 60 lifetime

reserve daysAll but $682 a day $682 a day $0

Once lifetime reserve days are used:

— Additional 365 days

$0100% of Medicare eligible expenses

$0**

— Beyond the additional 365 days

$0 $0 All costs

Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $170.50 a day $0 Up to $170.50 a day

101st day and after $0 $0 All costs

Blood

First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0

Hospice Care

You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

KY ONLY will need to place the extra disclaimer: (1 Plan A is not available as a Select Plan option.)


(continued)


Medical Expenses — In or Out of the Hospital and Outpatient Hospital Treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $185 of Medicare Approved Amounts*

$0 $0$185 (Part B deductible)

Remainder of Medicare Approved Amounts

Generally 80% Generally 20% $0

Part B Excess Charges

Above Medicare Approved Amounts $0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $185 of Medicare Approved Amounts*



80% 20% $0

Clinical Laboratory Services

Tests for Diagnostic Services 100% $0 $0

* Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.


Home Health Care — Medicare Approved Services

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment:

— First $185 of Medicare approved amounts*


— Remainder of Medicare approved amounts

80% 20% $0

Parts A & B Services

Medicare (Part B) – Medical Services – Per Calendar Year

Plan A

KY ONLY will need to place the extra disclaimer: (1 Plan A is not available as a Select Plan option.)


(continued)






First 60 days All but $1,364$1,364 (Part A deductible)

$0







$0**


$0 $0 All costs



21st thru 100th day All but $170.50 a day Up to $170.50 a day $0


Blood



Hospice Care




$0

Plan F


(continued)




$0$185 (Part B deductible)

$0




Above Medicare Approved Amounts $0 100% $0

Blood




$0


80% 20% $0









100% $0 $0




$0


80% 20% $0

Plan F


(continued)


Foreign Travel — Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

Remainder of Charges $080% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

Other Benefits – Not Covered by Medicare

Plan F


(continued)


(continued)







$0



reserve daysAll but $682 a day

$682 a day

$0




$0**


$0 $0 All costs



21st thru 100th dayAll but $170.50 a day

Up to $170.50 a day

$0


Blood



Hospice Care




$0

Innovative F


(continued)





$0





Blood




$0


80% 20% $0








100% $0 $0



$0— First $185 of Medicare approved amounts*


80% 20% $0





Innovative F


(continued)


Routine Vision BenefitThrough Blue View Vision Insight network you can maximize your benefits. You may receive covered benefits outside of the Blue View Vision Insight network. You will need to pay the provider at the time of service and submit a claim for reimbursement.

A. Routine Eye Exam (with dilation as needed) once every 12 months

$0

In Network: 100% after the CopaymentOut of Network: Up to $35 allowance

In Network: $25 copayOut of Network: Any amountsremaining afterthe Plan pays

B. Eyeglass Frames – Allowance toward new frames once every 24 months

$0

In-Network: $100 allowance

Out-of-Network: Up to $45 allowance

Any amounts remaining after the Plan pays

C. Lenses: Standard Plastic (CR39) – up to 55 mm in: Single Vision, Bifocal, Trifocal (FT 25-28), Lenticular (once every 12 months)

$0

In Network: 100% after the CopaymentOut of Network: Single Vision: Up to $25Bifocal: Up to $40Trifocal or Lenticular: Up to $55

In Network: $25 copayOut of Network: Any amountsremaining afterthe Plan pays

Contact Lenses (in place of eyeglass lenses) – once every 12 months

$0

In Network: $100 allowanceOut of Network: Up to $80 allowance

Any amounts remaining after the Plan pays

— Elective (conventional/disposable)

— Non-Elective $0In Network: All CostsOut of Network: Up to $210 allowance

Routine Hearing Benefit

Through Hearing Care Solutions network of providers, coverage is provided for an annual hearing

exam and hearing aid(s). This is separate from diagnostic hearing examinations and related

charges as covered by Medicare.

Hearing Exam – Coverage for up to (1) routine hearing exam every 12 months.

$0 100% $0

Hearing Aid(s) – Includes fitting evaluation for a hearing aid(s).

$0

Coverage allowance up to $750 toward a hearing device(s) every year. Includes 1-year supply of batteries (up to 64 cells per hearing aid).

Amounts in excess of Allowance

Innovative Benefits – Not Covered by Medicare or Standardized Medicare Supplement Plans

Innovative F


(continued)







$0







$0**


$0 $0 All costs





Blood



Hospice Care




$0

Plan G


(continued)









Blood





80% 20% $0




Plan G






100% $0 $0





80% 20% $0


(continued)


Plan G







(continued)







$0







$0**


$0 $0 All costs





Blood



Hospice Care




$0

Plan N


(continued)






Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.


Above Medicare Approved Amounts

$0 $0 All costs

Blood





80% 20% $0





Plan N


(continued)



100% $0 $0





80% 20% $0










Plan N


P.O. Box 659816

San Antonio, TX 78265-9116

Anthem Blue Cross is the trade name of Blue Cross of California. Independent

licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem

Insurance Companies, Inc.

75801CASENABC (Rev. 10_2019)

Medicare Supplement Outline of Coverage...Medicare Supplement Outline of Coverage Plans A, F,...

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