Anthem Senior Advantage Your Medicare coverage becomes more complete. M0013-07-007 09/2006 P-351 11/2006
Leaving the Plan We hope you won t, but if you want to disenroll, you may: Write a letter to Anthem Senior Advantage Call and request a disenrollment form which you can mail back to Anthem. Call 1 (800) MEDICARE (1 (800) 633-4227). TTY users should call 1 (877) 486-2048. Medicare customer service representatives are available 24 hours a day, including weekends, to answer questions about Medicare. If you choose to leave Anthem Senior Advantage, your disenrollment will be effective beginning on the first day of the next calendar month. We will send you a written notice of your official disenrollment date. Joining another Medicare Advantage plan will automatically disenroll you from Anthem Senior Advantage. Anthem Will End Your Coverage If You Fail to pay your Medicare Part B premium. Fail to pay your Anthem Senior Advantage premium. Move permanently outside the service area. Live outside the service area for more than six consecutive months. Impair our ability to serve you because your behavior is abusive or disruptive. Commit fraud or forgery. If we ask you to leave Anthem Senior Advantage, we will tell you our reasons in writing and explain how you can file a complaint against us if you wish to do so. Call to Get More Information Thank you for considering Anthem Blue Cross and Blue Shield. If you want to know more about the benefits of becoming a member of Anthem Senior Advantage, call an Anthem representative. We look forward to serving you. Inside Sales Office 1 (866) 803-5169 8 a.m. - 8 p.m., 7 days a week TDD System: for those with speech and hearing impairments and access to a TDD system, please call 711. Materials may be available in alternative formats. 8 8
Get More Coverage with Anthem Senior Advantage What is Anthem Senior Advantage? Anthem Senior Advantage (ASA) is a health maintenance organization (HMO) plan with a Medicare contract. Anthem Senior Advantage is offered to you by Anthem Blue Cross and Blue Shield. Anthem Senior Advantage is not a Medicare Supplement product. It is designed to offer more than Original Medicare. The Centers for Medicare & Medicaid Services (CMS) allow Anthem to administer all your Medicare benefits making Anthem Senior Advantage one complete plan. Some of the benefits include: Strength and Security with Anthem Blue Cross and Blue Shield Anthem Blue Cross and Blue Shield has been providing health care coverage for over 70 years. Today we belong to a family of companies that serves millions of members across the country. 2 Our mission is to improve the lives of the people we serve. We believe one way to help ensure good health is to offer benefits which cover immunizations, well visits, and health screenings. Preventive care Routine physicals Immunizations Mammograms and Pap smears Hospital care Skilled nursing care for 100 days Worldwide emergency care For a list of additional benefits, see your Summary of Benefits. The Summary also provides information about co-payments, coinsurance and premiums. 1 1 Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change January 1 of each year. 2 www.bcbsa.com Who We Are 1
How Can Anthem Senior Advantage Offer More than Medicare but Cost Less? Your Medicare dollars go further because our network doctors and hospitals agree to keep costs lower than original Medicare. That savings is passed on to you as more benefits and services. Anthem and Medicare Anthem Blue Cross and Blue Shield renews its contract with Medicare (the federal government) each year on January 1. Premiums and benefits may change at that time, but not during the year unless the change is to your advantage. If we do not renew our contract, we ll tell you at least 90 days in advance. You may then switch to a standard Medigap plan (A, B, C or F) that won t deny coverage because of a pre-existing condition. It will normally go into effect the day after your Anthem Senior Advantage membership ends. You Don t Need a Medical Exam to Qualify No need to bother with a medical exam! To qualify for Anthem Senior Advantage: You can be any age, but you must have Medicare Parts A and B. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by a third party. You will also pay for any Anthem Senior Advantage plan premium. You must live in the Anthem Senior Advantage service area.* Generally, you may not enroll if you have End Stage Renal Disease (kidney failure). Please contact Anthem for more information on exceptions to this rule. A Health Plan that Provides Access to a Diverse Network of Medical Professionals Our doctors and hospitals have been carefully screened to qualify as Anthem Senior Advantage network providers. They are listed in your Anthem Senior Advantage Provider Directory or you may access provider information through our Web site at www.anthem.com. Your doctor may be part of our network! The Advantage of Coordinated Care As an Anthem Senior Advantage member, you must have a primary care physician, who: Coordinates your health services. Refers you to network specialists. Admits you to network hospitals. Coordinates your paperwork. You must have your primary care physician s referral for most services. If you obtain routine care from out-of-network providers, neither Anthem Senior Advantage nor Medicare will pay for the service. The only exceptions are emergency and urgently needed care, out-of-area renal dialysis and services where you may self-refer (see the Summary of Benefits). 2 *Refer to the Summary of Benefits for a complete list of counties in your area.
You Only Need One Plan When you join Anthem Senior Advantage, you will automatically be cancelled from any previous Medicare Advantage plan. You cannot belong to two plans at once. However, you will not be automatically disenrolled from a Medigap, (Medicare Supplement) policy. You must contact the insurance company that provides your Medigap insurance and cancel your coverage. Do not cancel your current health coverage until you receive a written notice confirming your enrollment with Anthem. Your enrollment with Anthem Senior Advantage will normally be effective the first day of the month following receipt of your completed application. There are Rules for Switching Plans The Centers for Medicare & Medicaid Services (CMS) has limitations on when and how often you can change the way you get Medicare. Switching from one plan (like Anthem Senior Advantage) to one of the other plans that we offer, or to a plan offered by another organization, counts towards making a change. If you have both Medicare and Medicaid, you can change to another plan at any time. 1. From November 15 through December 31, anyone with Medicare has an opportunity to switch from one way of getting Medicare to another. 2. From January 1 until March 31, anyone with Medicare (including members of Anthem Senior Advantage) has another chance to make a change in the way they get Medicare. However, during the period between January 1 and March 31, you are limited in the type of plan you can join. You can t add or drop Medicare prescription drug coverage during this time. For example, if you have Medicare prescription drug coverage, you can only choose to join another plan that offers Medicare prescription drug coverage, or choose to return to the Original Medicare Plan and join a Medicare Prescription Drug Plan. If you don t have Medicare prescription drug coverage, you can t use this chance to get it. 3. Generally, you can t make any other changes during the year unless you meet special exceptions, such as if you move out of the plan s service area or if you have Medicaid coverage. Note: If you join another Medicare plan, including a Medicare Prescription Drug Plan, you will be disenrolled from our plan when your enrollment in the new plan begins. If you leave your current plan and do not join a plan that offers Medicare prescription drug coverage or a Medicare Prescription Drug Plan, and you do not have prescription drug coverage that is at least as good as the basic Medicare prescription drug benefit, you may have to pay a penalty if you decide to join later. This means your monthly premium will be higher. We Listen to Your Concerns We do our best to give our members all the information they need, and listen to their concerns. So Anthem Senior Advantage has both appeals and grievance procedures. We review complaints about quality of care (grievances) within 30 days. Issues about payment for services (appeals) will be addressed within 60 days. If the appeal is for a denied service, the reconsideration, decision must be made no later than 30 days after receipt. However, if your health is at stake, we are required to respond to the appeal within 72 hours. 7
Refuse to accept treatment, but your doctor must explain the consequences. Appoint someone to make care decisions for you when you are unable to do so. Receive written notice when Anthem decides not to provide benefits that pay for a service. Anthem will also tell you how to appeal the decision. File a complaint without fear of reprisal. Receive a yearly copy of your Anthem Senior Advantage Evidence of Coverage and Summary of Benefits. Written notice if our benefits or services change, and a notice if your doctor leaves Anthem s network (30 days prior to the change). If your specialist leaves Anthem s network, you can see him or her for 30 days after that. Anthem Senior Advantage Member Responsibilities As a member of Anthem Senior Advantage, you must: Select a primary care physician from the Anthem Senior Advantage Provider Directory to coordinate all your health care needs. If you do not select a primary care physician, Anthem will select one for you. Provide complete and honest information about your health care status. Follow your doctor s treatment plan. Understand how to access care in routine, urgent and emergency situations. You must know your out-of-service-area coverage, deductibles and co-payments. Tell your doctor or Anthem if you have concerns about your medical care or service. Be considerate of the rights of other members, providers and Anthem staff. Read and understand your Member Handbook, Evidence of Coverage and Summary of Benefits. Tell us honestly about other health care plans you may carry. Continue to pay for Medicare Part B, your plan premiums (if any) and your plan co-payments. Tell Anthem and your doctor what they need to know to provide benefits for you. We Hope You Decide to Become a Member Millions of Americans enjoy the benefits of Blue Cross and Blue Shield coverage. We hope you decide to become one of them by joining Anthem Senior Advantage. How to Enroll in Anthem Senior Advantage Read all these materials to decide if Anthem Senior Advantage is right for you. 1. Make sure you live in our service area. 2. Select your primary care physician from the Provider Directory. He or she must be a family or general practitioner, or internist. 3. Include a photocopy of your Medicare card. 4. Complete the application. 5. Make sure you ve signed and dated the application where needed. 6. Mail all items in the enclosed return envelope. Once we receive your application, someone from Anthem will verify your enrollment through Medicare. Do not cancel your current coverage until we tell you that your Anthem Senior Advantage coverage is in force. You will receive a notice confirming your enrollment, along with your Anthem Senior Advantage plan information. 6
Prescription Drug Coverage that Really Delivers Anthem Senior Advantage has convenient prescription drug benefits that help you control your out-of-pocket costs. Most available generic drugs are included in Anthem s formulary s formulary. An Anthem Senior Advantage prescription benefits also include: Reasonable copays Anthem Rx Direct mail service What about Medicare Part D? As a member of Anthem Senior Advantage, you are automatically enrolled in Medicare Part D, Medicare s new prescription drug coverage that became effective Jan. 1, 2006. You do not need to enroll in a separate Part D plan. In fact, if you enroll in a separate Part D plan while you are a member of Anthem Senior Advantage, you will automatically be disenrolled from the ASA plan. What is a Formulary? A formulary is a list of brand name and generic medications that have been rigorously reviewed by a committee of practicing doctors, clinical pharmacists and other health care professionals for their quality, effectiveness and, when appropriate, their cost effectiveness. You may help control the amount you pay for prescriptions by encouraging your doctor to prescribe medications from the Anthem formulary. Generic Drugs A generic drug has the same active ingredients as its brand-name counterpart. Normally, it is available only after the patent protection expires on a brand name drug. Even though it may look different, the Food and Drug Administration (FDA) requires the generic drug to work the same as its corresponding brand name medication. By using generic versions, you usually save money. Benefit Specifics The amount you pay when you fill a covered prescription is called your co-payment or coinsurance. These payments can vary, depending on the drug, and on whether you purchase the drug at a plan pharmacy or through our mail order service. When you fill a covered prescription, you pay either the co-payment, coinsurance, or the full cost of the prescription, whichever is lower. In-network Pharmacies The types of pharmacies included in our network are: Retail pharmacies Mail order pharmacies Long-term care pharmacies Home infusion pharmacies Generally, benefits are only available at our network pharmacies, except under emergency circumstances. Brand-name Drugs A brand-name drug is usually available only from one manufacturer and may have patent protection. 3
Out-of Network Pharmacies Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including illness while traveling outside the Plan s service area where there is no network pharmacy. In addition to paying the co-payment or coinsurance, you will be required to pay the difference between what Anthem would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charges for the prescription. Contact Anthem for more information on network and mail-order pharmacies. Assistance for Those with Limited Resources Beneficiaries who qualify for extra help with Medicare Prescription Drug Plan costs should call: 1 (800) MEDICARE, 1 (800) 633-4227; TTY/TDD users should call 1 (877) 486-2048, 24 hours a day/seven days a week; or Your state Medicaid office; or The Social Security Administration at 1 (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1 (800) 325-0778. If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs may be lower. When you join Anthem Senior Advantage, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you aren t getting any extra help, you can see if you qualify by calling: 1 (800) MEDICARE, 1 (800) 633-4227; TTY/TDD users should call 1 (877) 486-2048; or Your state Medicaid office; or The Social Security Administration at 1 (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1 (800) 325-0778. Emergency Services Emergency services are covered services that are furnished by a provider qualified to furnish emergency services and are needed to evaluate or stabilize an emergency medical condition. An emergency medical condition is one that occurs suddenly and results in acute or severe symptoms. An emergency medical condition is one in which prudent laypersons, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to their health or serious impairment to an or organ or body part. Some specific examples of emergency care include (but are not limited to): Bodily injury (e.g., car accident) Choking Convulsions/seizure Poisoning Respiratory arrest Shock Significant burn Unconsciousness In the event of an emergency, call 911 immediately or go straight to the near nearest emergency room. Anthem Senior Advantage will cover services provided in an emergency whether in or out of the service area. This includes worldwide emergency services as specified in the Summary of Benefits. As soon as possible after the emergency, you or your designated representative should telephone your PCP. This notification is important so that your PCP can be involved in the management of your follow-up care and transfer to a network facility can be arranged when your medical condition is stable. (Follow-up care is expected to be provided or arranged by your PCP.) 4
Urgent Care Services Urgently needed care is when you need medical attention right away for an unforeseen illness or injury, and it is not reasonable given the situation for you to get medical care from plan providers. In these cases, your health is not in serious danger. The main difference between urgent care and a medical emergency is in the level of danger to your health. Urgently needed care is when you need medical help immediately, but your health is not in serious danger. A medical emergency is when you believe that your health is in serious jeopardy. Some examples of urgent care services include (but are not limited to): Abdominal pain Abrasions Acute sunburn Earache Minor burn Minor cut/laceration Persistent nausea and vomiting Significant flu Significant sore throat Significant sprain No Surprises: We Want You to be Fully Informed Please take a moment to read this information before you decide to join: Anthem Senior Advantage Member Rights As a member of Anthem Senior Advantage, you have a right to: Be treated with dignity, respect, and the right to privacy. Timely access to your medical records, which must be kept private. Health care without being discriminated against for any reason. All the Anthem Senior Advantage benefits to which you are entitled. Be understood and treated well, even if you have limited English skills, a different cultural background, or a disability. Access emergency care without a doctor s referral. Choose your own doctor from your Anthem Senior Advantage Provider Directory. Be told how to select a new doctor from the Provider Directory. Refuse care from one provider and select a different provider. Take part in decisions about your health care treatment with your doctor. Participate in frank discussions of treatment options for your condition, regardless of cost or coverage. 5
For more information, visit our Web site at anthem.com. The information in this booklet is only an outline of some important features of Anthem Senior Advantage coverage. It is not intended to be a legal contract. The Evidence of Coverage you will receive describes most of the plan benefits and exclusions. In the event of a conflict between the Evidence of Coverage and this description, the terms of the Evidence of Coverage will prevail. Please read it carefully. In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. In Ohio: Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. M0013-07-007 09/2006 P-351 11/2006