2015 Outline of Medicare Supplement Coverage Cover Page (1 of 2) Plans A, F & N

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1 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Outline of Medicare Supplement Coverage Cover Page ( of ) Benefit Chart of Medicare Supplement Plans Sold for Effective Dates On or After June, 00 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. These same Plans are available to those who are under 65 and qualify for Medicare due to disability (except for ESRD). Basic Benefits: Hospitalization Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses Part B coinsurance (generally 0% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments. Blood First three pints of blood each year. Hospice Part A coinsurance. PLAN A B C D F F* G K L M N Basic coverage Skilled Nursing Facility Basic, including 00% Part B coinsurance Basic, including 00% Part B coinsurance Basic, including 00% Part B coinsurance Basic, including 00% Part B coinsurance Basic, including 00% Part B coinsurance* Basic, including 00% Part B coinsurance Hospitalization and preventive care paid at 00%; other basic benefits paid at 50% Hospitalization and preventive care paid at 00%; other basic benefits paid at 75% Basic, including 00% Part B coinsurance Basic, including 00% Part B coinsurance, except up to $0 copayment for office visit, and up to $50 copayment for ER coinsurance P P P P 50% 75% P P High Deductible Plan F is not available. WPOOC00M(Rev. 05 Outline of /5)-CA Medicare Supplement Coverage (continued on next page)

2 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Outline of Medicare Supplement Coverage Cover Page ( of ) PLAN A B C D F F* G K L M N Part A Deductible P P P P P 50% 75% 50% P Part B Deductible P P Part B Excess (00%) P P Foreign Travel Emergency P P P P P P Out-ofpocket limit $4,940; paid at 00% after limit reached $,470; paid at 00% after limit reached * 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 $,80 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $,80. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. High Deductible Plan F is not available. 05 Outline of Medicare Supplement Coverage

3 Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: About Your Premium Premium Information Effective March, 05 Premiums are subject to change. Here s some important information, before we get started: Premiums are subject to change on or after the Renewal Date in accordance with the terms of the Policy. Renewal Date is defined as generally March, subject to state approval. Your Premium Billing Preference does not guarantee your premium for any specific time period. Any state-approved premium changes will be applied starting on your next Renewal Date following your Coverage Effective Date, regardless of your Premium Billing Preference. The selected Premium Billing Preference will take effect on the first day of payment period which immediately follows your Coverage Effective Date. For example, if your Coverage Effective Date is September and you pick the Quarterly Premium Billing Preference, Quarterly premium billing will start on October ; if you select the Annual Premium Billing Preference, Annual premium billing will start on March. Any premiums billed for the period of time from your Coverage Effective Date to the start of your selected Premium Billing Preference will be prorated to reflect the Premium Billing Preference selected. 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 to determine your new attained age. Your premium may increase annually at your plan renewal based upon your new attained age. Don t miss out on a chance to SAVE! These optional discounts are offered. Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Save $ on your monthly premium! Enroll in our Automatic Bank Draft or Electronic Fund Transfer (EFT) program and you will save $ 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, 00 or after and available to those members who occupy the same housing unit. New to Medicare - Enroll in Plan F and SAVE $80! If you are age 65 or older, and within six months of your Part B effective date you will receive $5 off your monthly premium. This discount will apply for the first months of your policy. This discount is applicable to Plan F policies with an effective date of March, 05 or after. LET S BEGIN 05 Outline of Medicare Supplement Coverage 3

4 Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Find Your Monthly Premium Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Premium Information Effective March, 05 Premiums are subject to change. We re here to help you make choices to match your coverage needs. First, you ll need to locate 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 zip code where you live, tobacco use, age, plan, and the costs of medical services and supplies. After locating your monthly premium, you ll refer to individual plan pages. These pages will provide details of coverage and benefits, for comparison purposes. Here s how to find your premium, step-by-step: Step. Determine your Rating Area. Step. Determine which Premium Table applies to you. P Find your premium. First, you will use the Zip Code Area Guide to determine your Rating Area. Record your area below: If you are applying during your Open Enrollment Period or are eligible for Guaranteed Issue coverage, use Table. Otherwise, refer to the appropriate Premium Table, according to your tobacco use: If you did not use any tobacco products in the past months: > see Table. or If you did use any tobacco products in the past months: > see Table. Now you re ready to compare premiums for each plan available to you. We sort this information by age. 05 Outline of Medicare Supplement Coverage 4

5 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Determine Your Rating Area > Go to Column and locate the Prefix (first 3 digits of your Zip Code) (P.O. Box addresses are not acceptable.) 5-Digit Zip Code Area Guide > Next, move to Column and locate the last two digits of your Zip Code. (continued) > Column 3 is your Rating Area. (note: Some zip codes are assigned Multiple Rating Areas.*) P Got it? Now refer to your Premium Table. 3 Prefix (Last two digits of Zip Code) Area , 93-96, , , 0, 09-3, 0-4, 30-33, 39-4, 45, 47-5, 5 54, 55, 60-64, 66, 67, 70, 7, 74, 75, 77, 78, 80, 90, , 6* , 97, , 4, 3, 33, ,, 37, 39, 40, 50-5, 59-6, 70, , 30, 3, 38 4, 5* 907 0,, 40, 4, , 06, 07, 0-7, 3, 3-34, 44-49, Prefix (Last two digits of Zip Code) Area , 3-5,, 3-35, 40, 4, 44-48, 53, 5 88, 95, , 03, 06-, 6, 7, 0,, 3-5, 30, 3, , 46, 66, , 4-8,, 3-6, 9, 3, 8, 84, 85, 5 88, 89, 9, , 4,,, , 05, 06, 08-0, 3, 6,,, 4-35, 5 37, 40-46, 50-57, 63-65, 67, 7, 7, 76, 80-88, 90, 9-96, , 0, 58-60, , 07,, 6, 6 5, 6* , 6, 3, 6, 36, 70, 8, 95-97, , 0, -3, Prefix (Last two digits of Zip Code) Area 96 0-, , 4, 50, 59, 67-69, 73, , 0, 06, 08, 0, 4-6, -4, 9-40, , 5, 54-56, 58, 6-65, 70-7, 75, 76, 78, 80, 84-86, 88-93, 95, 98, , 66 5, 6* , 4, 96, , 05, 06, 08-7,, 3-35, 4-48, 50, 5, 6, 63, 76-80, 87, , 07-, 3, 4, 8-30, 33, 36-40, 46, 6 49, 5, 5, 54-6, 64-7, 74, 75, 78, 79, 8-86, 88, 90-93, , 6* 9 0-4, 6-40, 4, 43, 45, 47, 49, 50, 5-55, 58-79, 8, 84, 86, 87, * Counties With Zip Codes That Cross Rating Area Boundaries: Area Includes Calaveras, Inyo, Kings, Mendocino, Monterey, Placer, San Benito, Sutter, Tulare, Tuolumne, and Yolo. Area Includes Fresno, Imperial, Kern, Mariposa, Sacramento, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Sonoma, and Stanislaus. Area 3 Includes Alameda, Contra Costa, Santa Barbara, and Santa Clara. Area 4 Includes Orange. Area 5 Includes Los Angeles. Area 6 Includes Riverside, San Bernardino, San Diego, and Ventura. 05 Outline of Medicare Supplement Coverage (see next page for more zips) 5

6 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Determine Your Rating Area > Go to Column and locate the Prefix (first 3 digits of your Zip Code) (P.O. Box addresses are not acceptable.) 5-Digit Zip Code Area Guide > Next, move to Column and locate the last two digits of your Zip Code. (continued) > Column 3 is your Rating Area. (note: Some zip codes are assigned Multiple Rating Areas.*) P Got it? Now refer to your Premium Table. Prefix (Last two digits of Zip Code) 9, 7, 3-33, 43, 44, 49-5, 57, 59, 66, 73, 75, 8, , 0,, 0, 3, 6, 30, 34-36, 39-4, 47, 48, 5-56, 58, 60-64, 67, 68, 70, 76-78, 80, 8, 84-86, 9 3 Area 9 5, 74, 6* 93 8, 84, , 04, 05, 07-8, 0-7, 9, 3-4, 44-47, 50, 5, 54, 56-59, 63-66, 68, 69, 7-78, 8, 85, 86, 9-95, , 0-5, 8, 3, 4, , 3-9,,, 30-3, 36, 39, 43-46, 48, 49, 5-57, 6-64, 67, 70-7, 8-87, 89-93, 95, 96, , 09, 0,, 4-0, 3-30, 37, 46-63, 7-79, 83-85, 88, 90-94, 97, Prefix (Last two digits of Zip Code) Area 97 0-, 5, 8, 35, 80-8, ,,, 4-7, -3, 5, 3-38, 40-46, 4 50, 56, 57, 59, 6-7, 85-87, , , , 09-, 5, 6, 0-4, 30-36, 40-44, , 93, 94, , 6* , 05-, 6-8, 0,, 30, 40, 50, 60, 90, , 0, 04, 07, 08,, 8, 9,, 3, 7, 30, 3, 35, 37, 39, 44, 46, 47, 56-58, 60-6, 65-67, 70-7, 74, 75, 77-79, 8, 86, , 05, 06, 6, 0,, 4-6, 34, 40, 4, 49-5, 54, 55, 63, 68, 76, 80, 83, 85, 87 3 Prefix (Last two digits of Zip Code) Area 93 0, 5, 38, 4, 43, 45, 5-3, 5, 6* , -4, , 05-0,, 0-4, 7-30, 3-38, 40-49, 5-58, 60, 6, 63-65, 75, , 5, * 935-5, 7,, 6, 9, 30, 4, 4, 45, 46, , 0, 04, 05, 8, 9, 3, 4, 8, 3, 54, 56, 6, 8, , 3, 34-36, 39, 43, 44, 50-53, 58, 6, 6 63, 84, 86, , 7, 55, 60,, 5, 6* * Counties With Zip Codes That Cross Rating Area Boundaries: Area Includes Calaveras, Inyo, Kings, Mendocino, Monterey, Placer, San Benito, Sutter, Tulare, Tuolumne, and Yolo. Area Includes Fresno, Imperial, Kern, Mariposa, Sacramento, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Sonoma, and Stanislaus. Area 3 Includes Alameda, Contra Costa, Santa Barbara, and Santa Clara. Area 4 Includes Orange. Area 5 Includes Los Angeles. Area 6 Includes Riverside, San Bernardino, San Diego, and Ventura. 05 Outline of Medicare Supplement Coverage (see next page for more zips) 6

7 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Determine Your Rating Area > Go to Column and locate the Prefix (first 3 digits of your Zip Code) (P.O. Box addresses are not acceptable.) 5-Digit Zip Code Area Guide > Next, move to Column and locate the last two digits of your Zip Code. (continued) > Column 3 is your Rating Area. (note: Some zip codes are assigned Multiple Rating Areas.*) P Got it? Now refer to your Premium Table. 3 Prefix (Last two digits of Zip Code) Area , 5, 33, 47, 66, 70, , 0, 04-4, 6, 9-8, 30, 34-40, 4-45, 48-53, 57, 60-6, 64, 65, 67-69, , 3, 4, 46, 54, 56, * , 4-8, 0-30, 37, 40, 4, 44, 45, 47, 50, 55, 60, 6, 64, 65, 7-80, 84, 86, , , 0, 05-08,, 5, 0-8, 30, 3, 33, 40, 4-44, 50, 53-55, 60, , 05, 0,, 3-8, 30, 35, 37-44, 60-66, 3 70, 74, 80, 83, , 4-47, 50-56, 58-64, 7, 7, 75, 77, 3 88, ,, 9, 30, 3, 34-37, 39, 40, 44-50, 5, 54, 56-59, 6-63, 67-69, 7, 73, 74, 77-80, 8-9, Prefix (Last two digits of Zip Code) Area , , , 08, 0,, 5, 33-35, 58, 59, 6, 67, 7, 73, 74, 76, 8, 85, 89-9, , 0, 06, 07, 09,, 3, 6-3, 36-53, 55-57, 3 60, 6, 63-66, 68-70, 7, 75, 77-80, 8, 83, 86-88, , 4, 3* , 7-5, 49, 59-6, ,, , 0, , 3, 6-8, 3, 5-55, 7, 75, , 03, 04, -5, 0, 4, 5, 9, 30, 33, 37-4, 45-50, 56, 57, 60, 63-66, 70, 7, 73, 74, 76-79, Prefix (Last two digits of Zip Code) Area ,, 4, 39, 43, 45, , 03, 05-07, 0, 7-9, 4, 60-67, 73, , 08, 09,, 3-5, 0,, 6, 30-3, , 4, 44, 46, 50-56, 70, , 33, 76,, 3* 95 0, 03, 06, 08-3, 5-36, 38-4, 48, 50-6, 3 64, 70, 7, 73, 90-94, , 8, 9, 3, 33, 45-5, 54, 55, , 5, 9, 0, 7, 3, 34, 37, 40-4, 53, 58, 67, 69, 96, , 36, * , 09, 0, 4, 7, 35, 46, 47, 64, 70, 7, 73, 75, 79, 83 * Counties With Zip Codes That Cross Rating Area Boundaries: Area Includes Calaveras, Inyo, Kings, Mendocino, Monterey, Placer, San Benito, Sutter, Tulare, Tuolumne, and Yolo. Area Includes Fresno, Imperial, Kern, Mariposa, Sacramento, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Sonoma, and Stanislaus. Area 3 Includes Alameda, Contra Costa, Santa Barbara, and Santa Clara. Area 4 Includes Orange. Area 5 Includes Los Angeles. Area 6 Includes Riverside, San Bernardino, San Diego, and Ventura. 05 Outline of Medicare Supplement Coverage (see next page for more zips) 7

8 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Determine Your Rating Area > Go to Column and locate the Prefix (first 3 digits of your Zip Code) (P.O. Box addresses are not acceptable.) 5-Digit Zip Code Area Guide > Next, move to Column and locate the last two digits of your Zip Code. (continued) > Column 3 is your Rating Area. (note: Some zip codes are assigned Multiple Rating Areas.*) P Got it? Now refer to your Premium Table. Prefix (Last two digits of Zip Code) 953 0, 03, 04, 06, 07,, 3, 5-0, -6, 8, 30, 33, 34, 36-38, 40, 4, 43-45, 48, 50-58, 60, 6, 63, 65-69, 74, 76, 78, 80-8, 85-89, 97 3 Area 953,, 9, 77, 9,, 3* 954 0, 5, 7, 8, 0, -4, 6-9, 3, 35, 37, 43, 45, 49, 5, 53, 54, 56-6, 63, 64, 66-70, 8, 8, 85, 88, 90, 93, , 09,, 6, 9,, 30, 3, 33, 36, 39, 4, 4, 44, 46, 48, 50, 5, 6, 65, 7-73, 76, 80, 86, 87, 9, , * 3 Prefix (Last two digits of Zip Code) Area ,, 4, 8, 9,, 4-8, 3, 3, 34, 36-38, 40, 4, 43, 45-56, 58, 59, 60, 6-7, 73, 85, 87, 89, , -4, 7, 9, 3, 7, 9, 3, 33-37, 40, 4, 44-46, 48, 50, 5, 53, 54, 56, 58, 59, 6, 63-69, 7, 74-79, 8, 8, 84, 85, 89, 9, 9, 95, , 5, 0,, 4, 5, 8, 30, 3, 38, 39, 4, 5, 55, 60, 6, 70, 7, 73, 80, 83, 86-88, 90, 93, , 8, 6, 94, * 957 0, 03, 09, -5, 7, 0-, 4, 6, 8, 35, 36, 46, 47, 6, 65, 76, 98, 99 3 Prefix (Last two digits of Zip Code) Area 957 4, 4, 57-59, , 38, 40-43, 5-53, 60, 64-67, 87, 94, , 37, * 959 0, 03, 0, -0, -30, 3, 34-5, 53-63, 65-84, 86-88, , 06-, 3-7, 9-5, 7-9, 3-35, 37-4, 44, 46-5, 54-59, 6-65, 67-7, 73-76, 78-80, 84-97, , 03-30, 3-37, 40-43, 45, 46, 48, 50-5, 54-58, * Counties With Zip Codes That Cross Rating Area Boundaries: Area Includes Calaveras, Inyo, Kings, Mendocino, Monterey, Placer, San Benito, Sutter, Tulare, Tuolumne, and Yolo. Area Includes Fresno, Imperial, Kern, Mariposa, Sacramento, San Joaquin, San Luis Obispo, Santa Cruz, Solano, Sonoma, and Stanislaus. Area 3 Includes Alameda, Contra Costa, Santa Barbara, and Santa Clara. Area 4 Includes Orange. Area 5 Includes Los Angeles. Area 6 Includes Riverside, San Bernardino, San Diego, and Ventura. 05 Outline of Medicare Supplement Coverage (see next page for more zips) 8

9 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Find your Premium Table Non-Tobacco Users and/or Open Enrollment or Guaranteed Issue (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.) Premium is based upon your age, plan and area. Area Area Age* Plan A Plan F Plan N <65 $.59 $397. $ Age* Plan A Plan F Plan N <65 $.59 $397. $ * Attained age at the time of enrollment. 05 Outline of Medicare Supplement Coverage (see next page for more rating areas) 9

10 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Find your Premium Table Non-Tobacco Users and/or Open Enrollment or Guaranteed Issue (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.) Premium is based upon your age, plan and area. Area 3 Area 4 Age* Plan A Plan F Plan N <65 $.59 $397. $ Age* Plan A Plan F Plan N <65 $ $58.40 $ * Attained age at the time of enrollment. 05 Outline of Medicare Supplement Coverage (see next page for more rating areas) 0

11 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Find your Premium Table Non-Tobacco Users and/or Open Enrollment or Guaranteed Issue (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.) Premium is based upon your age, plan and area. Area 5 Area 6 Age* Plan A Plan F Plan N <65 $ $58.40 $ Age* Plan A Plan F Plan N <65 $9.07 $437.6 $ * Attained age at the time of enrollment. 05 Outline of Medicare Supplement Coverage (see next page for Table )

12 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Find your Premium Table For Tobacco Users (continued) If you have used tobacco products in the past months, use this table or if you are not a tobacco user, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table. Premium is based upon your age, plan and area. Area Area Age* Plan A Plan F Plan N <65 $48.8 $ $ Age* Plan A Plan F Plan N <65 $48.8 $ $ * Attained age at the time of enrollment. 05 Outline of Medicare Supplement Coverage (see next page for more rating areas)

13 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Find your Premium Table For Tobacco Users (continued) If you have used tobacco products in the past months, use this table or if you are not a tobacco user, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table. Premium is based upon your age, plan and area. Area 3 Area 4 Age* Plan A Plan F Plan N <65 $48.8 $ $ Age* Plan A Plan F Plan N <65 $ $580.6 $ * Attained age at the time of enrollment. 05 Outline of Medicare Supplement Coverage (see next page for more rating areas) 3

14 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Monthly Premium Effective March, 05 Premiums are subject to change. Step : Find your Premium Table For Tobacco Users (continued) If you have used tobacco products in the past months, use this table or if you are not a tobacco user, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table. Premium is based upon your age, plan and area. Area 5 Area 6 Age* Plan A Plan F Plan N <65 $ $580.6 $ Age* Plan A Plan F Plan N <65 $36.00 $490. $ * Attained age at the time of enrollment. 05 Outline of Medicare Supplement Coverage 4

15 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross Administrative Office: P.O. Box 9063, Oxnard, CA Toll Free Telephone Number: Disclosure Page 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, 05. 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 9063, Oxnard, CA 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. Retain this outline for your records. 05 Outline of Medicare Supplement Coverage 5

16 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details A Medicare (Part A) hospital services per benefit period Part A Services Services Medicare Pays Plan Pays You Pay Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $,60 $0 $,60 (Part A deductible) 6 st thru 90 th day All but $35 a day $35 a day $0 9 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 00% of Medicare eligible expenses $0** Beyond the additional 365 days $0 $0 All costs (continued on next page) * 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. 05 Outline of Medicare Supplement Coverage 6

17 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details A Medicare (Part A) hospital services per benefit period Part A Services Services Medicare Pays Plan Pays You Pay 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 0 days All approved amounts $0 $0 st thru 00 th day All but $57.50 a day $0 Up to $57.50 a day 0 st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 00% $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 * 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. $0 05 Outline of Medicare Supplement Coverage 7

18 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details A Medicare (Part B) medical services per calendar year Part B Services Services Medicare Pays Plan Pays You Pay 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 $47 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges Above Medicare Approved Amounts Blood $0 $0 $47 (Part B deductible) Generally 80% Generally 0% $0 $0 $0 All costs First 3 pints $0 All costs $0 Next $47 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Clinical Laboratory Services $0 $0 $47 (Part B deductible) 80% 0% $0 Tests for Diagnostic Services 00% $0 $0 * Once you have been billed $47 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. 05 Outline of Medicare Supplement Coverage 8

19 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details A Medicare (Part A) hospital & (Part B) medical services Parts A+B Services Services Medicare Pays Plan Pays You Pay Home Health Care Medicare Approved Services Medically necessary skilled care services 00% $0 $0 and medical supplies Durable medical equipment: First $47 of Medicare approved amounts* $0 $0 $47 (Part B deductible) Remainder of Medicare approved amounts 80% 0% $0 * Once you have been billed $47 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. 05 Outline of Medicare Supplement Coverage 9

20 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details F Medicare (Part A) hospital services per benefit period Part A Services Services Medicare Pays Plan Pays You Pay Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $,60 $,60 (Part A deductible) $0 6 st thru 90 th day All but $35 a day $35 a day $0 9 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 00% of Medicare eligible expenses $0** Beyond the additional 365 days $0 $0 All costs (continued on next page) * 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. 05 Outline of Medicare Supplement Coverage 0

21 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details F Medicare (Part A) hospital services per benefit period Part A Services Services Medicare Pays Plan Pays You Pay 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 0 days All approved amounts $0 $0 st thru 00 th day All but $57.50 a day Up to $57.50 a day $0 0 st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 00% $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 * 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. $0 05 Outline of Medicare Supplement Coverage

22 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details F Medicare (Part B) medical services per calendar year Part B Services Services Medicare Pays Plan Pays You Pay 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 $47 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges Above Medicare Approved Amounts Blood $0 $47 (Part B deductible) $0 Generally 80% Generally 0% $0 $0 00% $0 First 3 pints $0 All costs $0 Next $47 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Clinical Laboratory Services $0 $47 (Part B deductible) $0 80% 0% $0 Tests for Diagnostic Services 00% $0 $0 * Once you have been billed $47 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. 05 Outline of Medicare Supplement Coverage

23 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details F Medicare (Part A) hospital & (Part B) medical services other benefits not covered by Medicare Parts A+B Services Services Medicare Pays Plan Pays You Pay Home Health Care Medicare Approved Services Medically necessary skilled care services 00% $0 $0 and medical supplies Durable medical equipment: First $47 of Medicare approved amounts* $0 $47 (Part B deductible) $0 Remainder of Medicare approved amounts 80% 0% $0 Other benefits Not Covered by Medicare Foreign Travel Not Covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $50 each calendar year $0 $0 $50 80% to a lifetime maximum 0% and amounts over the Remainder of Charges $0 benefit of $50,000 $50,000 lifetime maximum * Once you have been billed $47 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. 05 Outline of Medicare Supplement Coverage 3

24 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details N Medicare (Part A) hospital services per benefit period Part A Services Services Medicare Pays Plan Pays You Pay Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $,60 $,60 (Part A deductible) $0 6 st thru 90 th day All but $35 a day $35 a day $0 9 st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 00% of Medicare eligible expenses $0** Beyond the additional 365 days $0 $0 All costs (continued on next page) * 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. 05 Outline of Medicare Supplement Coverage 4

25 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details N Medicare (Part A) hospital services per benefit period Part A Services Services Medicare Pays Plan Pays You Pay 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 0 days All approved amounts $0 $0 st thru 00 th day All but $57.50 a day Up to $57.50 a day $0 0 st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 00% $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 * 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. $0 05 Outline of Medicare Supplement Coverage 5

26 Plan Steve Shorr Insurance - Authorized Agent For more information and to very the latest details N Medicare (Part B) medical services per calendar year Part B Services Services Medicare Pays Plan Pays You Pay 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 $47 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges Above Medicare Approved Amounts Blood $0 $0 $47 (Part B deductible) Generally 80% Balance, other than up to $0 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. $0 $0 All costs First 3 pints $0 All costs $0 Next $47 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Up to $0 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. $0 $0 $47 (Part B deductible) 80% 0% $0 (continued on next page) * Once you have been billed $47 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. 05 Outline of Medicare Supplement Coverage 6

27 Part Part B Services Services Plan N Medicare (Part B) medical services per calendar year Medicare (Part A) hospital & (Part B) medical services other benefits not covered by Medicare Services Medicare Pays Plan Pays You Pay Clinical Laboratory Services Tests for Diagnostic Services 00% $0 $0 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Parts A+B Services Home Health Care Medicare Approved Services Medically necessary skilled care services 00% $0 $0 and medical supplies Durable medical equipment: First $47 of Medicare approved amounts* $0 $0 $47 (Part B deductible) Remainder of Medicare approved amounts 80% 0% $0 Other benefits Not Covered by Medicare Foreign Travel Not Covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $50 each calendar year $0 $0 $50 80% to a lifetime maximum 0% and amounts over the Remainder of Charges $0 benefit of $50,000 $50,000 lifetime maximum * Once you have been billed $47 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. 05 Outline of Medicare Supplement Coverage 7

28 Steve Shorr Insurance - Authorized Agent For more information and to very the latest details Anthem Blue Cross is the trade name of Blue Cross of. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.