Anthem Blue Cross and Blue Shield Ohio Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169 Benefit Chart of Medicare Supplement Plans Sold for Effective Dates On or After June 1, 2010 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 in your state. Plans shown in gray are available for purchase. Plans noted with a triangle are Medicare Select Plans and contain the same benefits, except for restrictions on your use of hospitals. Basic, including 100% Part B 2013 Outline of Medicare Supplement Coverage Cover Page Plans A, F, High Ded F, G & N Plan A B C D F F* G K L M N Basic, Basic, Basic, Basic, Basic, Hospitalization Hospitalization Basic, including including including including including and preventive and preventive including 100% 100% 100% 100% 100% care paid care paid 100% Part B Part B Part B Part B Part B at 100%; other at 100%; other Part B * basic benefits basic benefits paid at 50% paid at 75% Part A Deductible Skilled Nursing Facility Part A Deductible Part B Deductible Foreign Travel Emergency Skilled Nursing Facility Part A Deductible Foreign Travel Emergency Skilled Nursing Facility Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic Benefits: Hospitalization Part A plus coverage for 365 additional days after Medicare benefits end. Medical Expenses Part B (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B or copayments. Blood First three pints of blood each year. Hospice Part A. Skilled Nursing Facility Part A Deductible Part B Excess (100%) Foreign Travel Emergency 50% Skilled Nursing Facility 50% Part A Deductible Out-of-pocket limit $4,800; paid at 100% after limit reached 75% Skilled Nursing Facility 75% Part A Deductible Out-of-pocket limit $2,400; paid at 100% after limit reached Skilled Nursing Facility 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Part A Deductible Foreign Travel Emergency * Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include WPOOC001M(Rev.8/11)-OH 2013 Outline of Medicare the Supplement Medicare deductibles Coverage for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. 1
Anthem Blue Cross and Blue Shield Ohio Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169 Monthly Rates Plans A, F, High Ded F, G & N Effective July 1, 2013 Rates are subject to change. Premium Information We, Anthem, can only raise your premium if we raise the premium for all plans like yours in this State. Your premium rate increases based upon your attained age. We will recalculate your age each year. Your premium rate will increase annually based upon your new attained age. Premium changes due to your attained age occur at the beginning of your policy term. Attained Age A F High Ded F G N 65 $ 108.91 $ 159.42 $ 58.30 $ 147.17 $ 117.28 66 111.72 169.02 61.80 156.77 124.36 67 114.14 178.63 65.32 166.38 131.42 68 119.32 188.23 68.82 175.98 138.49 69 124.44 197.84 72.34 185.59 145.55 70 129.86 207.44 75.86 195.19 152.62 71 135.26 217.05 79.36 204.80 159.69 72 140.58 226.65 82.88 214.40 166.75 73 145.99 236.26 86.39 224.01 173.82 74 151.30 245.86 89.90 233.61 180.89 75 156.18 255.47 93.42 241.43 187.95 76 161.07 263.87 96.92 248.99 195.02 77 165.94 271.86 100.44 256.52 202.08 78 170.83 279.87 106.73 264.08 209.16 79 175.38 287.36 110.34 271.12 216.22 80 179.45 293.94 113.95 277.37 223.29 81+ 182.83 299.52 113.95 282.62 223.29 2013 Outline of Medicare Supplement Coverage 2
Anthem Blue Cross and Blue Shield Ohio Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169 Monthly Rates Plans F, High Ded F, G & N Effective January 1, 2013 Rates are subject to change. Premium Information Select Plans (must use a network hospital) Rates below are effective for all zip codes not in Cuyahoga county. We, Anthem, can only raise your premium if we raise the premium for all plans like yours in this State. Your premium rate increases based upon your attained age. We will recalculate your age each year. Your premium rate will increase annually based upon your new attained age. Premium changes due to your attained age occur at the beginning of your policy term. Attained Age F High Ded F G N 65 $ 130.68 $ 45.74 $ 120.23 $ 90.17 66 137.93 48.27 126.90 95.17 67 145.32 50.86 133.69 100.27 68 152.52 53.38 140.32 105.24 69 157.61 55.16 145.00 108.75 70 162.92 57.02 149.88 112.41 71 168.20 58.87 154.75 116.05 72 173.33 60.67 159.47 119.59 73 179.48 62.82 165.12 123.84 74 185.63 64.97 170.78 128.08 75 191.99 67.20 176.64 132.47 76 198.14 69.35 182.29 136.72 77 201.95 70.68 185.80 139.34 78 208.32 72.91 191.65 143.74 79 214.50 75.07 197.34 148.01 80 221.09 77.38 203.40 152.56 81+ 227.45 79.61 209.25 156.95 2013 Outline of Medicare Supplement Coverage 3
Anthem Blue Cross and Blue Shield Ohio Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169 Monthly Rates Plans F, High Ded F, G & N Effective January 1, 2013 Rates are subject to change. Premium Information Select Plans (must use a network hospital) Rates below are effective for the following ZIP codes: 44017, 44022, 44040, 44070, 44101-44147, 44149, 44177-44179, 44181, 44184-44186, 44188-44195, 44197-44199. We, Anthem, can only raise your premium if we raise the premium for all plans like yours in this State. Your premium rate increases based upon your attained age. We will recalculate your age each year. Your premium rate will increase annually based upon your new attained age. Premium changes due to your attained age occur at the beginning of your policy term. Attained Age F High Ded F G N 65 $ 139.31 $ 48.76 $ 128.17 $ 96.12 66 147.03 51.45 135.27 101.45 67 154.91 54.22 142.52 106.89 68 162.59 56.91 149.59 112.18 69 168.01 58.80 154.56 115.93 70 173.67 60.78 159.77 119.83 71 179.30 62.75 164.96 123.72 72 184.77 64.68 169.99 127.49 73 191.33 66.96 176.02 132.01 74 197.88 69.26 182.04 136.54 75 204.66 71.64 188.29 141.22 76 211.22 73.93 194.32 145.75 77 215.28 75.35 198.06 148.53 78 222.07 77.73 204.30 153.23 79 228.66 80.02 210.37 157.77 80 235.68 82.49 216.83 162.62 81+ 242.46 84.86 223.06 167.31 2013 Outline of Medicare Supplement Coverage 4
Anthem Blue Cross and Blue Shield Ohio Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169 Premium Information (con t) Monthly Rates Plans A, F, High Ded F, G & N Effective January 1, 2013 Rates are subject to change. 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.) OR 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. 2013 Outline of Medicare Supplement Coverage 5
Anthem Blue Cross and Blue Shield Ohio Administrative Office: P.O. Box 659806, San Antonio, TX 78265-9106 Toll Free Telephone Number: 1-866-803-5169 Disclosure Page Plans A, F, High Ded F, G, & N Disclosures Use this outline to compare benefits and premiums among policies. Medicare deductibles and amounts are effective as of January 1, 2013. 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. 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 659806, San Antonio, TX 78265 9106. 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 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. Retain this outline for your records. 2013 Outline of Medicare Supplement Coverage 6
PLAN A MEDICARE (PART A) SERVICES PER BENEFIT PERIOD * 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. Services Medicare Pays Plan Pays You Pay IZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,184 61 st thru 90 th day All but $296 a day $296 a day 91 st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: Additional 365 days All but $592 a day $592 a day 100% of Medicare eligible expenses $1,184 (Part A Beyond the additional 365 days 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 21 st thru 100 th day All but $148 a day Up to $148 a day 101 st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ ** 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. ** 2013 Outline of Medicare Supplement Coverage 7
PLAN A MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $147 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. Services Medicare Pays Plan Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE AND OUTPATIENT 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 $147 of Medicare Approved Amounts* Remainder of Medicare Approved Generally 80% Amounts Generally 20% Part B Excess Charges Above Medicare Approved Amounts All costs BLOOD First 3 pints All costs Next $147 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare approved amounts* Remainder of Medicare approved amounts 100% 80% 20% 2013 Outline of Medicare Supplement Coverage 8
PLAN F MEDICARE (PART A) SERVICES PER BENEFIT PERIOD * 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. Services Medicare Pays Plan Pays You Pay IZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,184 $1,184 (Part A 61 st thru 90 th day All but $296 a day $296 a day 91 st day and after: While using 60 lifetime reserve All but $592 a day $592 a day days Once lifetime reserve days are used: Additional 365 days 100% of Medicare eligible expenses ** 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. ** Beyond the additional 365 days 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 21 st thru 100 th day All but $148 a day Up to $148 a day 101 st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ 2013 Outline of Medicare Supplement Coverage 9
PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $147 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. Services Medicare Pays Plan Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE AND OUTPATIENT 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 $147 of Medicare Approved Amounts* Remainder of Medicare Approved Generally 80% Amounts Generally 20% Part B Excess Charges Above Medicare Approved Amounts 100% BLOOD First 3 pints All costs Next $147 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare approved amounts* Remainder of Medicare approved amounts OTHER BENEFITS NOT COVERED BY MEDICARE 2013 Outline of Medicare Supplement Coverage 10 100% 80% 20% FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum
HIGH PLAN DEDUCTIBLE PLAN F MEDICARE (PART A) SERVICES PER BENEFIT PERIOD * 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. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. Services Medicare Pays After You Pay $2,110 Deductible,** Plan Pays IZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,184 $1,184 (Part A 61 st thru 90 th day All but $296 a day $296 a day 91 st day and after: While using 60 lifetime reserve All but $592 a day $592 a day days Once lifetime reserve days are used: Additional 365 days 100% of Medicare eligible expenses ** Beyond the additional 365 days 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 21 st thru 100 th day All but $148 a day Up to $148 a day 101 st day and after All costs In Addition to $2,110 Deductible,** You Pay (Continued) *** 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. 2013 Outline of Medicare Supplement Coverage 11
HIGH PLAN DEDUCTIBLE PLAN F MEDICARE (PART A) SERVICES PER BENEFIT PERIOD (Continued) * 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. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. Services Medicare Pays After You Pay $2,110 Deductible,** Plan Pays BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ In Addition to $2,110 Deductible,** You Pay *** 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. 2013 Outline of Medicare Supplement Coverage 12
HIGH PLAN DEDUCTIBLE PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $147 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. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. Services MEDICAL EXPENSES IN OR OUT OF THE AND OUTPATIENT 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 $147 of Medicare Approved Amounts* Remainder of Medicare Approved Medicare Pays After You Pay $2,110 Deductible,** Plan Pays Generally 80% Generally 20% Amounts Part B Excess Charges Above Medicare Approved Amounts 100% BLOOD First 3 pints All costs Next $147 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare approved amounts* Remainder of Medicare approved amounts 100% 80% 20% In Addition to $2,110 Deductible,** You Pay (Continued) 2013 Outline of Medicare Supplement Coverage 13
HIGH PLAN DEDUCTIBLE PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR (Continued) * Once you have been billed $147 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. ** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays After You Pay $2,110 Deductible,** Plan Pays FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 In Addition to $2,110 Deductible,** You Pay 20% and amounts over the $50,000 lifetime maximum 2013 Outline of Medicare Supplement Coverage 14
PLAN G MEDICARE (PART A) SERVICES PER BENEFIT PERIOD * 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. Services Medicare Pays Plan Pays You Pay IZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,184 $1,184 (Part A 61 st thru 90 th day All but $296 a day $296 a day 91 st day and after: While using 60 lifetime reserve All but $592 a day $592 a day days Once lifetime reserve days are used: Additional 365 days 100% of Medicare eligible expenses ** 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. ** Beyond the additional 365 days 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 21 st thru 100 th day All but $148 a day Up to $148 a day 101 st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ 2013 Outline of Medicare Supplement Coverage 15
PLAN G MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $147 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. Services Medicare Pays Plan Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE AND OUTPATIENT 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 $147 of Medicare Approved Amounts* Remainder of Medicare Approved Generally 80% Amounts Generally 20% Part B Excess Charges Above Medicare Approved Amounts 100% BLOOD First 3 pints All costs Next $147 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare approved amounts* Remainder of Medicare approved amounts OTHER BENEFITS NOT COVERED BY MEDICARE 100% 80% 20% FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 2013 Outline of Medicare Supplement Coverage 16
PLAN N MEDICARE (PART A) SERVICES PER BENEFIT PERIOD * 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. Services Medicare Pays Plan Pays You Pay IZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,184 $1,184 (Part A 61 st thru 90 th day All but $296 a day $296 a day 91 st day and after: While using 60 lifetime reserve All but $592 a day $592 a day days Once lifetime reserve days are used: Additional 365 days 100% of Medicare eligible expenses ** 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. ** Beyond the additional 365 days 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 21 st thru 100 th day All but $148 a day Up to $148 a day 101 st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ for outpatient drugs and inpatient respite care Medicare copayment/ 2013 Outline of Medicare Supplement Coverage 17
PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once you have been billed $147 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. Services Medicare Pays Plan Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE AND OUTPATIENT 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 $147 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment 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. Part B Excess Charges Above Medicare Approved Amounts All costs BLOOD First 3 pints All costs Next $147 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for Diagnostic Services 100% Up to $20 per office visit and up to $50 per emergency room visit. The copayment 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. (Continued) 2013 Outline of Medicare Supplement Coverage 18
PLAN N MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR (Continued) PARTS A & B Services Medicare Pays Plan Pays You Pay HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment: First $147 of Medicare approved amounts* Remainder of Medicare approved amounts OTHER BENEFITS NOT COVERED BY MEDICARE 100% 80% 20% FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of Charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 2013 Outline of Medicare Supplement Coverage 19
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross 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 Blue Shield Association.
S ASHLAND COUNTY, OH OHIO DEFIANCE COUNTY, OH OHIO ASHLAND COUNTY Samaritan Regional Health System 1025 Center St Ashland, OH 44805 419-289-0491 ASHTABULA COUNTY Ashtabula County Medical Center 2420 Lake Ave Ashtabula, OH 44004 440-997-2262 BUTLER COUNTY Bethesda Hospital Inc 3055 Hamilton Mason Rd Hamilton, OH 45011 513-454-1410 Bethesda Hospital Inc 3125 Hamilton Mason Rd Hamilton, OH 45011 513-894-8888 Mccullough Hyde 110 N Poplar Oxford, OH 45056 513-523-2111 Mercy Hospital Fairfield 3000 Mack Rd Fairfield, OH 45014 513-870-7000 CLERMONT COUNTY Mercy Hospital Clermont 3000 Hospital Dr Batavia, OH 45103 513-732-8200 COSHOCTON COUNTY Coshocton County Memorial Hospital 1460 Orange St Coshocton, OH 43812 740-622-6411 CRAWFORD COUNTY Galion Community Hospital 269 Portland Way S Galion, OH 44833 419-468-4841 CUYAHOGA COUNTY Cleveland Clinic 9500 Euclid Ave Cleveland, OH 44195 216-444-2200 Euclid Hospital 18901 Lakeshore Cleveland, OH 44119 216-531-9000 Fairview General Hospital 18101 Lorain Ave Cleveland, OH 44101 216-476-7000 Hillcrest Hospital 6780 Mayfield Rd Cleveland, OH 44124 440-449-4500 Lakewood Hospital 14519 Detroit Ave Lakewood, OH 44107 216-521-4200 Lutheran Medical Center 1730 W 25th St Cleveland, OH 44113 216-696-4300 Marymount Hospital 12300 Mccracken Rd Cleveland, OH 44125 216-581-0500 Parma Comm General Hospital 7007 Powers Blvd Cleveland, OH 44129 440-743-3000 South Pointe Hospital 20000 Harvard Rd Warrensvl Hts, OH 44122 216-491-6000 Southwest General Hospital 18697 E Bagley Rd Cleveland, OH 44130 440-816-8000 REHABILITATION Cleveland Clinic Childrens Rehab Hospita 2801 Martin Luther King Jr Dr Cleveland, OH 44104 216-721-5400 DEFIANCE COUNTY Defiance Regional Medical Center 1200 Ralston Ave Defiance, OH 43512 419-783-6955 FOR THE MOST UP-TO-DATE INFORMATION CALL THE CUSTOMER SERVICE NUMBER LISTED ON YOUR MEMBER ID CARD OR VISIT WWW.ANTHEM.COM. 1 THIS LISTING WAS COMPILED AS OF APRIL 2013. ANTHEM HAS MADE REASONABLE EFFORTS TO VALIDATE THAT THIS DIRECTORY OF PROVIDERS IS UP TO DATE AND ACCURATE. PLEASE CALL THE PROVIDER PRIOR TO SCHEDULING AN APPOINTMENT TO VERIFY THAT THE PROVIDER CONTINUES TO BE PART OF THE NETWORK. ANTHEM SHALL NOT BE LIABLE FOR ANY LOSSES, DAMAGES, OR UNCOVERED CHARGES AS A RESULT OF USING THIS PROVIDER DIRECTORY OR RECEIVING CARE FROM A PROVIDER LISTED IN THIS DIRECTORY.
S DELAWARE COUNTY, OH OHIO LORAIN COUNTY, OH DELAWARE COUNTY Ohio State University Hospital 6515 Pullman Dr Lewis Center, OH 43035 614-388-7130 ERIE COUNTY Firelands Regional Medical Center 1111 Hayes Ave Sandusky, OH 44870 419-557-7400 FAIRFIELD COUNTY Fairfield Medical Center 401 N Ewing St Lancaster, OH 43130 740-687-8000 FRANKLIN COUNTY Arthur James Cancer Inst 1145 Olentangy River Rd Columbus, OH 43212 614-293-5066 Arthur James Cancer Inst 300 W 10th Ave Columbus, OH 43210 614-293-3300 Doctors Hospital 5100 W Broad St Columbus, OH 43228 614-544-1000 Dublin Methodist Hospital 7500 Hospital Dr Dublin, OH 43016 614-544-8000 Grant Medical Center 111 S Grant Ave Columbus, OH 43215 614-566-9000 Ohio State University Hospital 1492 E Broad St Columbus, OH 43205 614-293-8000 Ohio State University Hospital 410 W 10th Ave Columbus, OH 43210 614-293-8000 Riverside Methodist Hospital 3535 Olentangy River Rd Columbus, OH 43214 614-566-5000 FULTON COUNTY Fulton County Health Center 725 S Shoop Ave Wauseon, OH 43567 419-335-2015 HAMILTON COUNTY Bethesda Hospital Inc 10500 Montgomery Rd Cincinnati, OH 45242 513-569-6111 Bethesda Hospital Inc 10615 Montgomery Rd Cincinnati, OH 45242 513-793-1999 Good Samaritan Hospital 375 Dixmyth Ave Cincinnati, OH 45220 513-862-1400 Mercy Franciscan Hospital Mt Airy 2446 Kipling Ave Cincinnati, OH 45239 513-853-5000 Mercy Franciscan Hospital Western Hills 3131 Queen City Ave Cincinnati, OH 45238 513-389-5000 Mercy Hospital Anderson 7500 State Rd Cincinnati, OH 45255 513-624-4500 HOLMES COUNTY Joel Pomerene Memorial Hospital 981 Wooster Rd Millersburg, OH 44654 330-674-1015 LORAIN COUNTY Emh Regional Medical Center 254 Cleveland Ave Amherst, OH 44001 440-988-6000 Emh Regional Medical Center 630 E River St Elyria, OH 44035 440-329-7500 FOR THE MOST UP-TO-DATE INFORMATION CALL THE CUSTOMER SERVICE NUMBER LISTED ON YOUR MEMBER ID CARD OR VISIT WWW.ANTHEM.COM. 2 THIS LISTING WAS COMPILED AS OF APRIL 2013. ANTHEM HAS MADE REASONABLE EFFORTS TO VALIDATE THAT THIS DIRECTORY OF PROVIDERS IS UP TO DATE AND ACCURATE. PLEASE CALL THE PROVIDER PRIOR TO SCHEDULING AN APPOINTMENT TO VERIFY THAT THE PROVIDER CONTINUES TO BE PART OF THE NETWORK. ANTHEM SHALL NOT BE LIABLE FOR ANY LOSSES, DAMAGES, OR UNCOVERED CHARGES AS A RESULT OF USING THIS PROVIDER DIRECTORY OR RECEIVING CARE FROM A PROVIDER LISTED IN THIS DIRECTORY.
S LUCAS COUNTY, OH OHIO SUMMIT COUNTY, OH LUCAS COUNTY Bay Park Community Hospital 2801 Bay Park Dr Oregon, OH 43616 419-690-7900 Flower Memorial Hospital 5200 Harroun Rd Sylvania, OH 43560 419-824-1444 Mercy St Charles Hospital 2600 Navarre Ave Oregon, OH 43616 419-696-7200 St Lukes Hospital 5901 Monclova Rd Maumee, OH 43537 419-893-5911 Toledo Hospital 2142 N Cove Blvd Toledo, OH 43606 419-291-4000 REHABILITATION St Lukes Hospital 5901 Monclova Rd Maumee, OH 43537 419-893-5911 MAHONING COUNTY Northside Medical Center 500 Gypsy Ln Youngstown, OH 44501 330-884-1000 St Elizabeth Boardman Health Center 8401 Market St Boardman, OH 44512 330-729-2929 St Elizabeth Health Center 1044 Belmont Ave Po Box 1790 Youngstown, OH 44504 330-746-7211 MENTAL HEALTH/SUBSTANCE ABUSE FACILITY Belmont Pines Hospital 615 Churchill-hubbard Rd Youngstown, OH 44505 330-759-2700 REHABILITATION Greenbriar Rehabilitation Hospital 8064 South Ave Ste 1 Boardman, OH 44512 330-965-6432 MEDINA COUNTY Lodi Community Hospital 225 Elyria St Lodi, OH 44254 330-948-1222 Medina General Hospital 1000 E Washington St Medina, OH 44256 330-725-1000 PICKAWAY COUNTY Berger Health System 600 N Pickaway St Circleville, OH 43113 740-474-2126 PORTAGE COUNTY Robinson Memorial Hospital 6847 N Chestnut St Ravenna, OH 44266 330-297-0811 SENECA COUNTY Fostoria Community Hospital 501 Van Buren St Fostoria, OH 44830 419-435-7734 STARK COUNTY Affinity Medical Center 875 8th St Ne Massillon, OH 44646 330-837-7200 Alliance Community Hospital 200 E State St Alliance, OH 44601 330-596-6000 Mercy Medical Center 1320 Mercy Dr N W Canton, OH 44708 330-489-1000 SUMMIT COUNTY Akron General Medical Center 400 Wabash Ave Akron, OH 44307 330-384-6082 FOR THE MOST UP-TO-DATE INFORMATION CALL THE CUSTOMER SERVICE NUMBER LISTED ON YOUR MEMBER ID CARD OR VISIT WWW.ANTHEM.COM. 3 THIS LISTING WAS COMPILED AS OF APRIL 2013. ANTHEM HAS MADE REASONABLE EFFORTS TO VALIDATE THAT THIS DIRECTORY OF PROVIDERS IS UP TO DATE AND ACCURATE. PLEASE CALL THE PROVIDER PRIOR TO SCHEDULING AN APPOINTMENT TO VERIFY THAT THE PROVIDER CONTINUES TO BE PART OF THE NETWORK. ANTHEM SHALL NOT BE LIABLE FOR ANY LOSSES, DAMAGES, OR UNCOVERED CHARGES AS A RESULT OF USING THIS PROVIDER DIRECTORY OR RECEIVING CARE FROM A PROVIDER LISTED IN THIS DIRECTORY.
S SUMMIT COUNTY, OH OHIO RANDOLPH COUNTY, IN Cleveland Clinic 8701 Darrow Rd Twinsburg, OH 44087 216-444-2200 Crystal Clinic Orthopaedic Center Llc 444 N Main St Akron, OH 44310 330-668-4040 Edwin Shaw Rehab 330 Broadway St E Cuyahoga Falls, OH 44221 330-436-0910 Summa Barberton Citizens Hospital 155 5th St Barberton, OH 44203 330-745-1611 Summa Health System 444 N Main St Akron, OH 44310 330-375-3000 Summa Health System 525 E Market St Akron, OH 44309 330-375-3000 Summa Western Reserve Hospital 1900 23rd St Cuyahoga Falls, OH 44223 330-971-7000 TRUMBULL COUNTY St Joseph Health Center 667 Eastland Ave Se Warren, OH 44484 330-841-4000 Trumbull Memorial Hospital 1350 E Market St Warren, OH 44482 330-841-9011 REHABILITATION Hillside Rehabilitation Hospital 8747 Squires Ln Ne Warren, OH 44484 330-841-3700 TUSCARAWAS COUNTY Trinity Hospital Twin City 819 N 1st St Dennison, OH 44621 740-922-2800 WARREN COUNTY Atrium Medical Ctr One Medical Center Dr Middletown, OH 45005 513-424-2111 WAYNE COUNTY Aultman Orrville Hospital 832 S Main St Orrville, OH 44667 330-682-3010 INDIANA ADAMS COUNTY Adams Memorial Hospital 1100 Mercer Ave Decatur, IN 46733 260-724-2145 ALLEN COUNTY Parkview Regional Medical Center 11109 Parkview Plaza Dr Fort Wayne, IN 46845 260-373-4000 Parkview Regional Medical Center 2200 Randallia Dr Fort Wayne, IN 46805 260-373-4000 REHABILITATION Parkview Hospital Inc 2200 Randallia Dr Fort Wayne, IN 46805 260-373-4000 DE KALB COUNTY Dekalb Memorial Hospital Inc 1316 E 7th St Auburn, IN 46706 260-925-4600 RANDOLPH COUNTY St Vincent Randolph Hospital 473 E Greenville Ave Winchester, IN 47394 765-584-0004 FOR THE MOST UP-TO-DATE INFORMATION CALL THE CUSTOMER SERVICE NUMBER LISTED ON YOUR MEMBER ID CARD OR VISIT WWW.ANTHEM.COM. 4 THIS LISTING WAS COMPILED AS OF APRIL 2013. ANTHEM HAS MADE REASONABLE EFFORTS TO VALIDATE THAT THIS DIRECTORY OF PROVIDERS IS UP TO DATE AND ACCURATE. PLEASE CALL THE PROVIDER PRIOR TO SCHEDULING AN APPOINTMENT TO VERIFY THAT THE PROVIDER CONTINUES TO BE PART OF THE NETWORK. ANTHEM SHALL NOT BE LIABLE FOR ANY LOSSES, DAMAGES, OR UNCOVERED CHARGES AS A RESULT OF USING THIS PROVIDER DIRECTORY OR RECEIVING CARE FROM A PROVIDER LISTED IN THIS DIRECTORY.
S STEUBEN COUNTY, IN OHIO KENTON COUNTY, KY STEUBEN COUNTY Cameron Memorial Comm Hospital Inc 416 E Maumee St Angola, IN 46703 260-665-2141 KENTUCKY BOONE COUNTY St Elizabeth Healthcare 4900 Houston Rd Florence, KY 41042 859-212-5200 KENTON COUNTY St Elizabeth Healthcare 1 Medical Village Dr Edgewood, KY 41017 859-344-2000 St Elizabeth Healthcare 1500 James Simpson Jr Way Covington, KY 41011 859-292-4000 BOYD COUNTY Our Lady Of Bellefonte 1000 Saint Christopher Dr Ashland, KY 41101 606-833-3333 CAMPBELL COUNTY St Elizabeth Healthcare 85 N Grand Ave Fort Thomas, KY 41075 859-572-3100 FOR THE MOST UP-TO-DATE INFORMATION CALL THE CUSTOMER SERVICE NUMBER LISTED ON YOUR MEMBER ID CARD OR VISIT WWW.ANTHEM.COM. 5 THIS LISTING WAS COMPILED AS OF APRIL 2013. ANTHEM HAS MADE REASONABLE EFFORTS TO VALIDATE THAT THIS DIRECTORY OF PROVIDERS IS UP TO DATE AND ACCURATE. PLEASE CALL THE PROVIDER PRIOR TO SCHEDULING AN APPOINTMENT TO VERIFY THAT THE PROVIDER CONTINUES TO BE PART OF THE NETWORK. ANTHEM SHALL NOT BE LIABLE FOR ANY LOSSES, DAMAGES, OR UNCOVERED CHARGES AS A RESULT OF USING THIS PROVIDER DIRECTORY OR RECEIVING CARE FROM A PROVIDER LISTED IN THIS DIRECTORY.
Adams Memorial Hospital Index Trumbull Memorial Hospital A Adams Memorial Hospital... 4 Affinity Medical Center... 3 Akron General Medical Center... 3 Alliance Community Hospital... 3 Arthur James Cancer Inst... 2 Ashtabula County Medical Center... 1 Atrium Medical Ctr... 4 Aultman Orrville Hospital... 4 B Bay Park Community Hospital... 3 Belmont Pines Hospital... 3 Berger Health System... 3 Bethesda Hospital Inc... 1, 2 C Cameron Memorial Comm Hospital Inc... 5 Cleveland Clinic... 1, 4 Cleveland Clinic Childrens Rehab Hospita... 1 Coshocton County Memorial Hospital... 1 Crystal Clinic Orthopaedic Center Llc... 4 D Defiance Regional Medical Center... 1 Dekalb Memorial Hospital Inc... 4 Doctors Hospital... 2 Dublin Methodist Hospital... 2 E Edwin Shaw Rehab... 4 Emh Regional Medical Center... 2 Euclid Hospital... 1 F Fairfield Medical Center... 2 Fairview General Hospital... 1 Firelands Regional Medical Center... 2 Flower Memorial Hospital... 3 Fostoria Community Hospital... 3 Fulton County Health Center... 2 G Galion Community Hospital... 1 Good Samaritan Hospital... 2 Grant Medical Center... 2 Greenbriar Rehabilitation Hospital... 3 H Hillcrest Hospital... 1 Hillside Rehabilitation Hospital... 4 J Joel Pomerene Memorial Hospital... 2 L Lakewood Hospital...1 Lodi Community Hospital...3 Lutheran Medical Center...1 M Marymount Hospital...1 Mccullough Hyde...1 Medina General Hospital...3 Mercy Franciscan Hospital Mt Airy...2 Mercy Franciscan Hospital Western Hills...2 Mercy Hospital Anderson...2 Mercy Hospital Clermont...1 Mercy Hospital Fairfield...1 Mercy Medical Center...3 Mercy St Charles Hospital...3 N Northside Medical Center...3 O Ohio State University Hospital...2 Our Lady Of Bellefonte...5 P Parkview Hospital Inc...4 Parkview Regional Medical Center...4 Parma Comm General Hospital...1 R Riverside Methodist Hospital...2 Robinson Memorial Hospital...3 S Samaritan Regional Health System...1 South Pointe Hospital...1 Southwest General Hospital...1 St Elizabeth Boardman Health Center...3 St Elizabeth Health Center...3 St Elizabeth Healthcare...5 St Joseph Health Center...4 St Lukes Hospital...3 St Vincent Randolph Hospital...4 Summa Barberton Citizens Hospital...4 Summa Health System...4 Summa Western Reserve Hospital...4 T Toledo Hospital...3 Trinity Hospital Twin City...4 Trumbull Memorial Hospital...4 6