Medicare Supplement Outline of Coverage

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

Anthem Blue Cross and Blue Shield Indiana 2021

This booklet includes: 2021 Premium Rates 2020 Medicare deductibles, copays and maximum out-of-pocket costs

Call toll-free 1-866-649-2033 with questions. Administrative Office: P.O. Box 659816, San Antonio, TX 78265-9116

AOOC001M(Rev. 2/20)-IN-T

2021 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 $2,340 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.

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

A B D G1 K L M NMedicare Part A coinsurance andhospital coverage (up to an additional 365 days after Medicare benefits are used up)

P P P P P P P P

Medicare Part B coinsurance or copayment

P P P P 50 % 75 % PP

copays apply3

Blood (first three pints) P P P P 50 % 75 % P PPart A hospice care coinsurance or copayment

P P P P 50 % 75 % P PSkilled nursing facility coinsurance P P 50 % 75 % P PMedicare Part A deductible P P P 50 % 75 % 50 % PMedicare Part B deductible

Medicare Part B excess charges PForeign travel emergency (up to plan limits)

P P P POut-of-pocket limit in 20202 $5,8802 $2,9402

Plans Available to All Applicants

C F 1

P P1

P P

P P

P P

P P

P P

P P

P

P P

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 to those age 65 and over.Note: A “P” means 100% of the benefit is paid.

Benefits


Finding Your Monthly Premium

Plans A, F, G & N | Effective January 1, 2021 Premiums are subject to change.

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

We, Anthem, 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 January 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 January 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 the county where you live, tobacco use, age, gender, plan, and the costs of medical services and supplies.

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

Premium Information

STEP 2: Determine Which Premium Table Applies to You

STEP 1: Determine Your Rating Area

Find Your Premium

PP

NOW … You Are Ready to Compare Plan Premiums

•Tobacco / Non-Tobacco

•Male / Female




Ways to Enroll Sales Department*

Call 1-866-803-5169 (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

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

Let’s Begin

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

Customer Service

Call 1-866-649-2033 (TTY/TDD: 711)

8 a.m. to 6 p.m. ET Monday - Friday

Visit us Online

www.anthem.com

- 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 Funds 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 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 May 1, 2018 or after.

Don’t miss out on a chance to SAVE!These optional discounts are offered.




Step 1: Determine Your Rating Area County Area Guide

PP

Area 1

• Boone

• Hamilton

• Hancock

• Johnson

• Monroe

• Morgan

• Shelby

• St Joseph

Area 2

All counties outside of Areas 1 & 3

Area 3

• Jasper

• La Porte

• Lake

• Newton

• Porter

• Starke

Find the county you live in from the list below.

Got Your Rating Area? Now you are ready to go to Step #2.



Plans A, F, G & N | Effective January 1, 2021 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan.

Find Your Premium (continued)

If you have not used tobacco products in the past 12 months, use this table.

Table 1 | Non-tobacco

Area 1

* Attained age at the time of enrollment.

(see next page for more areas)

Age

* Male Female

Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N

65 $144.42 $167.71 $123.59 $122.73 $130.47 $148.58 $111.68 $110.8966 152.00 179.49 130.45 129.55 137.32 159.25 117.86 117.03 67 159.58 191.25 137.29 136.35 144.18 169.87 124.04 123.18 68 167.14 203.04 144.14 143.14 151.00 180.53 130.23 129.32 69 174.70 214.81 150.99 149.95 157.84 191.17 136.41 135.48 70 182.26 226.59 157.84 156.75 164.67 201.80 142.60 141.62 71 189.84 238.37 164.69 163.54 171.51 212.45 148.80 147.77 72 197.39 250.15 171.53 170.34 178.33 223.11 154.98 153.90 73 204.96 261.92 178.37 177.13 185.17 233.74 161.16 160.05 74 212.52 273.73 185.23 183.95 192.01 244.38 167.35 166.18 75 220.10 285.49 192.08 190.76 198.86 255.01 173.55 172.34 76 227.65 297.28 198.92 197.54 205.67 265.67 179.71 178.47 77 235.23 309.05 205.77 204.35 212.52 276.31 185.90 184.62 78 242.80 320.83 212.63 211.15 219.38 286.95 192.10 190.77 79 250.37 332.61 219.47 217.94 226.20 297.58 198.29 196.92

80+ 257.94 344.40 226.31 224.74 233.05 308.25 204.46 203.04

Under Age 65 Premiums – For those qualified for Medicare by reason other than age.

Male Female

Plan A Plan A

$600.00 $600.00




Find Your Premium Find Your Premium (continued)



Area 2


Age

* Male Female


65 $154.52 $181.52 $132.23 $131.31 $139.59 $161.08 $119.48 $118.6566 162.62 194.14 139.56 138.60 146.92 172.48 126.09 125.22 67 170.72 206.71 146.89 145.88 154.25 183.85 132.71 131.79 68 178.82 219.35 154.21 153.15 161.55 195.25 139.34 138.36 69 186.91 231.93 161.55 160.42 168.87 206.64 145.95 144.95 70 194.99 244.53 168.87 167.69 176.18 218.02 152.57 151.51 71 203.10 257.14 176.21 174.98 183.50 229.39 159.21 158.10 72 211.18 269.75 183.51 182.24 190.80 240.80 165.79 164.65 73 219.28 282.33 190.83 189.52 198.11 252.18 172.41 171.21 74 227.38 294.96 198.17 196.79 205.42 263.57 179.04 177.79 75 235.48 307.54 205.50 204.09 212.75 274.94 185.66 184.37 76 243.56 320.15 212.82 211.35 220.05 286.33 192.27 190.95 77 251.66 332.77 220.15 218.64 227.38 297.72 198.90 197.52 78 259.77 345.36 227.49 225.90 234.71 309.12 205.52 204.11 79 267.87 357.96 234.81 233.17 242.00 320.49 212.14 210.68

80+ 275.97 370.58 242.12 240.44 249.33 331.88 218.75 217.23



Male Female

Plan A Plan A

$600.00 $600.00







Area 3

(see next page for Table 2)

Age

* Male Female


65 $182.02 $219.21 $166.83 $165.67 $164.43 $195.12 $150.73 $149.6966 191.56 234.08 176.09 174.85 173.07 208.55 159.08 157.98 67 201.12 248.88 185.32 184.04 181.70 221.94 167.43 166.29 68 210.65 263.76 194.56 193.21 190.30 235.37 175.78 174.56 69 220.19 278.60 203.81 202.40 198.92 248.79 184.14 182.85 70 229.69 293.43 213.05 211.58 207.53 262.19 192.49 191.15 71 239.25 308.28 222.30 220.76 216.15 275.61 200.85 199.45 72 248.76 323.14 231.52 229.92 224.75 289.04 209.17 207.74 73 258.31 337.96 240.78 239.09 233.37 302.43 217.53 216.02 74 267.84 352.82 250.03 248.28 241.98 315.86 225.88 224.33 75 277.39 367.66 259.28 257.47 250.62 329.25 234.24 232.62 76 286.91 382.51 268.50 266.65 259.20 342.68 242.58 240.90 77 296.46 397.35 277.75 275.83 267.84 356.09 250.94 249.20 78 306.00 412.20 287.01 285.02 276.48 369.51 259.30 257.50 79 315.55 427.04 296.25 294.19 285.08 382.89 267.65 265.80

80+ 325.09 441.91 305.47 303.35 293.71 396.33 275.98 274.06



Male Female

Plan A Plan A

$600.00 $600.00




Find Your Premium (continued)

If you have used tobacco products in the past 12 months, use this table.

Table 2 | For Tobacco Users

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

Area 1



Age

* Male Female


65 $161.75 $187.84 $138.42 $137.46 $146.13 $166.41 $125.08 $124.2066 170.24 201.03 146.10 145.10 153.80 178.36 132.00 131.07 67 178.73 214.20 153.76 152.71 161.48 190.25 138.92 137.96 68 187.20 227.40 161.44 160.32 169.12 202.19 145.86 144.84 69 195.66 240.59 169.11 167.94 176.78 214.11 152.78 151.74 70 204.13 253.78 176.78 175.56 184.43 226.02 159.71 158.61 71 212.62 266.97 184.45 183.16 192.09 237.94 166.66 165.50 72 221.08 280.17 192.11 190.78 199.73 249.88 173.58 172.37 73 229.56 293.35 199.77 198.39 207.39 261.79 180.50 179.26 74 238.02 306.58 207.46 206.02 215.05 273.71 187.43 186.12 75 246.51 319.75 215.13 213.65 222.72 285.61 194.38 193.02 76 254.97 332.95 222.79 221.24 230.35 297.55 201.28 199.89 77 263.46 346.14 230.46 228.87 238.02 309.47 208.21 206.77 78 271.94 359.33 238.15 236.49 245.71 321.38 215.15 213.66 79 280.41 372.52 245.81 244.09 253.34 333.29 222.08 220.55

80+ 288.89 385.73 253.47 251.71 261.02 345.24 229.00 227.40


Male Female

Plan A Plan A

$672.00 $672.00








Area 2



Age

* Male Female


65 $173.06 $203.30 $148.10 $147.07 $156.34 $180.41 $133.82 $132.8966 182.13 217.44 156.31 155.23 164.55 193.18 141.22 140.25 67 191.21 231.52 164.52 163.39 172.76 205.91 148.64 147.60 68 200.28 245.67 172.72 171.53 180.94 218.68 156.06 154.96 69 209.34 259.76 180.94 179.67 189.13 231.44 163.46 162.34 70 218.39 273.87 189.13 187.81 197.32 244.18 170.88 169.69 71 227.47 288.00 197.36 195.98 205.52 256.92 178.32 177.07 72 236.52 302.12 205.53 204.11 213.70 269.70 185.68 184.41 73 245.59 316.21 213.73 212.26 221.88 282.44 193.10 191.76 74 254.67 330.36 221.95 220.40 230.07 295.20 200.52 199.12 75 263.74 344.44 230.16 228.58 238.28 307.93 207.94 206.49 76 272.79 358.57 238.36 236.71 246.46 320.69 215.34 213.86 77 281.86 372.70 246.57 244.88 254.67 333.45 222.77 221.22 78 290.94 386.80 254.79 253.01 262.88 346.21 230.18 228.60 79 300.01 400.92 262.99 261.15 271.04 358.95 237.60 235.96

80+ 309.09 415.05 271.17 269.29 279.25 371.71 245.00 243.30


Male Female

Plan A Plan A

$672.00 $672.00








Area 3


Age

* Male Female


65 $203.86 $245.52 $186.85 $185.55 $184.16 $218.53 $168.82 $167.6566 214.55 262.17 197.22 195.83 193.84 233.58 178.17 176.94 67 225.25 278.75 207.56 206.12 203.50 248.57 187.52 186.24 68 235.93 295.41 217.91 216.40 213.14 263.61 196.87 195.51 69 246.61 312.03 228.27 226.69 222.79 278.64 206.24 204.79 70 257.25 328.64 238.62 236.97 232.43 293.65 215.59 214.09 71 267.96 345.27 248.98 247.25 242.09 308.68 224.95 223.38 72 278.61 361.92 259.30 257.51 251.72 323.72 234.27 232.67 73 289.31 378.52 269.67 267.78 261.37 338.72 243.63 241.94 74 299.98 395.16 280.03 278.07 271.02 353.76 252.99 251.25 75 310.68 411.78 290.39 288.37 280.69 368.76 262.35 260.53 76 321.34 428.41 300.72 298.65 290.30 383.80 271.69 269.81 77 332.04 445.03 311.08 308.93 299.98 398.82 281.05 279.10 78 342.72 461.66 321.45 319.22 309.66 413.85 290.42 288.40 79 353.42 478.28 331.80 329.49 319.29 428.84 299.77 297.70

80+ 364.10 494.94 342.13 339.75 328.96 443.89 309.10 306.95


Male Female

Plan A Plan A

$672.00 $672.00


Important Plan Disclosures

Plans A, 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, 2020. 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 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 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 $1,408 $0 $1,408 (Part A deductible)

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:• While using 60 lifetime

reserve days All but $704 a day $704 a day $0

• Once lifetime reserve days are used:

— Additional 365 days $0 100% 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 $176 a day $0 Up to $176 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.) 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 $198 of Medicare Approved Amounts* $0 $0 $198

(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 $198 of Medicare Approved Amounts* $0 $0 $198

(Part B deductible)

Remainder of Medicare Approved Amounts 80% 20% $0

▼ Clinical Laboratory Services

Tests for Diagnostic Services 100% $0 $0

* Once you have been billed $198 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 $198 of Medicare approved amounts* $0 $0 $198

(Part B deductible)

— 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 $1,408 $1,408 (Part A deductible) $0










21st thru 100th day All but $176 a day Up to $176 a day $0


▼ Blood



▼ Hospice Care




$0

Plan F


(continued)



First $198 of Medicare Approved Amounts* $0 $198

(Part B deductible) $0



Above Medicare Approved Amounts $0 100% $0

▼ Blood


Next $198 of Medicare Approved Amounts* $0 $198











100% $0 $0


— First $198 of Medicare approved amounts* $0 $198



Plan F


(continued)




100% $0 $0


— First $198 of Medicare approved amounts* $0 $198




▼ 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)


















▼ Blood



▼ Hospice Care




$0

Plan G


(continued)




(Part B deductible)



Above Medicare Approved Amounts $0 100% $0

▼ Blood

First 3 pints $0 All costs $0Next $198 of Medicare Approved Amounts* $0 $0 $198

(Part B deductible)Remainder of Medicare Approved Amounts 80% 20% $0




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





100% $0 $0



(Part B deductible)



(continued)




100% $0 $0



(Part B deductible)



Plan G







(continued)


















▼ Blood



▼ Hospice Care




$0

Plan N


(continued)




(Part B deductible)

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 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


Next $198 of Medicare Approved Amounts* $0 $0 $198

(Part B deductible)






Plan N


(continued)



100% $0 $0



(Part B deductible)











Plan N


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

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. (AICI) and Community Insurance Company (CIC). Plans A, G & N are offered by AICI. Plan F is offered by CIC. Independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

75801INSENABS (Rev. 10_2020)

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Medicare Supplement Outline of Coverage

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