Medicare Supplement Outline of Coverage. Plans A, F, G & N Anthem Blue Cross and Blue Shield Missouri 2018

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March 2, 2018 12:01 PM OOC18_MS_MO-T_DUAL-AFGN-AOOC001M(18)-MO-T_03-01-2018 Medicare Supplement Outline of Coverage Plans A, F, G & N Anthem Blue Cross and Blue Shield Missouri 2018 This booklet includes premium rates, Medicare deductibles, copays and maximum out-of-pocket costs. Call toll-free 1-800-490-6217 with questions. Administrative Office: P.O. Box 659816, San Antonio, TX 78265-9116 AOOC001M(18)-MO-T

Benefit Chart of Medicare Supplement Plans Sold 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. These same plans are available to those who are under 65 and qualify for Medicare due to disability. Basic Benefits Hospitalization Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses Part B coinsurance (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 coinsurance or copayments. Blood First three pints of blood each year. Hospice Part A coinsurance. Benefits A B C D F F* 1 G K L M N Basic Coverage, Including 100% Part B Coinsurance Hospitalization & Preventative Care /Other Basic Benefits Skilled Nursing Facility Coinsurance P P P P P * P P P s 100% /50% 100% /75% P P P P 50% 75% P P Part A Deductible P P P P P 50% 75% 50% P Part B Deductible P P Part B Excess (100%) P P Foreign Travel Emergency P P P P P P Out-of-pocket Limit; Paid at 100% after Limit is Reached $5,240 $2,620 * 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 $2,240 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,240. 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. 1 High Deductible Plan F is not available. s Basic benefits, EXCEPT up to $20 copayment for office visit, and up to $50 copayment for emergency room visit. 1

Finding Premium Your Information Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 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. 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 tobacco use, age, gender, plan, and the costs of medical services and supplies. Here s how to find your premium, step-by-step: StEP 1: Determine Your Rating Area StEP 2: Determine Which Premium table Applies to You Tobacco / Non-Tobacco Male / Female P Find Your Premium NOW You Are Ready to Compare Plan Premiums 2

Premium Finding the Information Right Plan for You Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. 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! Don t miss out on a chance to SAVE! These optional discounts are offered for all of the following Premium Tables, for ages 65 and over. 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. Ways to Enroll Sales Department * Call 1-800-652-6387 (TTY/TDD: 711) 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30 Customer Service Call 1-800-490-6217 (TTY/TDD: 711) 8 a.m. to 8 p.m., Monday through Friday Visit us Online www.anthem.com - Enroll online - Find a doctor - Find a pharmacy - List of covered drugs Let s Begin * By calling this number, you will reach an authorized licensed insurance agent who can answer questions about our plans and enrollment. 3

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Step 1: Determine Your Rating Area County Area Guide Find the county you live in from the list below. P Got Your Rating Area? Now you are ready to go to Step #2. Area 1 Area 2 Area 3 All counties outside Areas 2 & 3, but within the Anthem Blue Cross and Blue Shield service area. St. Louis County Franklin Jefferson Lincoln St. Charles St. Louis City Warren 4

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan. Find Your Premium Table 1 Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Area 1 Male Female Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N < 65 $133.63 $239.44 $216.28 $147. 53 $133.63 $239.44 $216.28 $147. 5 3 65 113.16 177.18 136.01 123.64 102.31 156.35 122.97 111.79 66 123.81 197.22 148.52 135.02 111.97 174.54 134.32 122.11 67 126.47 203.08 152.21 138.37 114.38 179.84 137.65 125.14 68 129.52 209.24 156.08 141.89 117.13 185.41 141.15 128.32 69 132.76 215.67 160.07 145.52 120.07 191.22 144.77 131.61 70 136.26 222.89 164.59 149.63 123.23 197.76 148.86 135.33 71 139.56 229.33 168.68 153.34 126.23 203.58 152.55 138.68 72 142.74 236.05 172.88 157.16 129.09 209.66 156.35 142.13 73 145.54 241.70 176.43 160.39 131.63 214.77 159.56 145.05 74 148.40 247.35 179.90 163.55 134.21 219.88 162.70 147. 91 75 151.04 252.99 183.46 166.78 136.60 224.97 165.91 150.83 76 153.77 258.70 187.05 170.05 139.07 230.14 169.17 153.79 77 156.56 264.26 190.52 173.20 141.59 235.17 172.32 156.65 78 158.90 268.83 193.35 175.77 143.71 239.30 174. 87 158.98 79 161.10 273.38 196.24 178.40 145.70 243.42 177.4 8 161.35 80 163.43 277. 87 199.06 180.97 147. 81 247.48 180.03 163.66 81 165.70 282.56 201.95 183.59 149.87 251.73 182.64 166.04 82 167.97 287.05 204.76 186.15 151.91 255.77 185.19 168.35 83 169.98 291.03 207.26 188.42 153.73 259.38 187.4 5 170.41 84 171.87 294.93 209.70 190.63 155.44 262.90 189.65 172.41 85 173.74 298.77 212.12 192.84 157.13 266.38 191.84 174.40 86 175.69 302.67 214.54 195.04 158.90 269.90 194.03 176.40 87 177.6 4 306.72 217.11 197.37 160.65 273.58 196.36 178.51 88 180.95 312.22 220.53 200.48 163.64 278.55 199.45 181.31 89 183.59 317.7 2 224.00 203.64 166.05 283.51 202.59 184.17 90 186.32 323.21 227.42 206.74 168.52 288.48 205.67 186.97 91 188.98 328.98 231.02 210.02 170.91 293.71 208.94 189.94 92 191.51 334.36 234.38 213.07 173.21 298.56 211.97 192.70 93 + 230.57 412.81 283.53 257.75 208.51 369.53 256.42 233.11 Age* * Age as of the date the plan is issued. (see next page for more areas) 5

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan. Find Your Premium Table 1 Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Area 12 Male Female Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N < 65 $133.63 $239.44 $216.28 $147. 53 $133.63 $239.44 $216.28 $147. 53 65 120.13 190.56 144.39 131.26 108.61 168.45 130.54 118.68 66 131.44 211.84 157.67 143.34 118.87 187.76 142.60 129.63 67 134.26 218.06 161.59 146.90 121.42 193.39 146.14 132.85 68 137.50 224.60 165.69 150.63 124.35 199.30 149.85 136.23 69 140.94 231.42 169.94 154.49 127.46 205.47 153.69 139.72 70 144.66 239.09 174.74 158.85 130.82 212.41 158.03 143.67 71 148.16 245.93 179.07 162.79 134.00 218.59 161.95 147.22 72 151.53 253.06 183.53 166.85 137.05 225.05 165.98 150.89 73 154.51 259.06 187.30 170.27 139.74 230.47 169.39 153.99 74 157.54 265.05 190.99 173.62 142.48 235.89 172.73 157.03 75 160.35 271.04 194.76 177.06 145.02 241.30 176.14 160.13 76 163.25 277.11 198.58 180.53 147.6 4 246.79 179.60 163.27 77 166.20 283.01 202.26 183.88 150.31 252.13 182.94 166.31 78 168.69 287.86 205.27 186.61 152.56 256.51 185.65 168.77 79 171.03 292.69 208.34 189.40 154.67 260.88 188.42 171.29 80 173.50 297.46 211.33 192.12 156.91 265.19 191.12 173.75 81 175.92 302.44 214.40 194.91 159.10 269.71 193.90 176.27 82 178.32 307.20 217.38 197.62 161.27 274.00 196.60 178.73 83 180.45 311.43 220.03 200.03 163.20 277. 83 199.01 180.91 84 182.47 315.57 222.62 202.38 165.02 281.57 201.34 183.04 85 184.45 319.64 225.19 204.72 166.81 285.26 203.67 185.15 86 186.52 323.78 227.77 207.06 168.69 289.00 205.99 187.27 87 188.58 328.09 230.49 209.53 170.55 292.90 208.46 189.51 88 192.10 333.92 234.12 212.83 173.73 298.18 211.74 192.49 89 194.91 339.76 237.80 216.18 176.28 303.45 215.07 195.52 90 197. 80 345.60 241.43 219.48 178.90 308.72 218.34 198.49 91 200.62 351.72 245.26 222.96 181.44 314.28 221.81 201.65 92 203.31 357.42 248.82 226.20 183.88 319.42 225.03 204.57 93 + 244.77 440.72 301.00 273.63 221.36 394.77 272.22 247.47 Age* * Age as of the date the plan is issued. (see next page for more areas) 6

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan. Find Your Premium Table 1 Non-tobacco If you have not used tobacco products in the past 12 months, use this table. Area 23 Male Female Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N < 65 $133.63 $239.44 $216.28 $147. 53 $133.63 $239.44 $216.28 $147.53 65 136.03 221.09 163.50 148.64 122.99 196.05 147. 83 134.39 66 148.84 245.18 178.55 162.32 134.61 217.91 161.48 146.80 67 152.03 252.22 182.98 166.35 137.50 224.29 165.48 150.44 68 155.70 259.63 187.63 170.57 140.81 230.98 169.69 154.26 69 159.59 267.35 192.43 174.94 144.34 237.96 174.03 158.21 70 163.81 276.03 197. 87 179.88 148.14 245.83 178.95 162.68 71 167.78 283.78 202.78 184.34 151.74 252.82 183.39 166.71 72 171.59 291.86 207.83 188.94 155.19 260.14 187.95 170.87 73 174.96 298.65 212.09 192.81 158.24 266.27 191.81 174.38 74 178.40 305.44 216.27 196.61 161.34 272.41 195.60 177. 81 75 181.58 312.22 220.54 200.50 164.22 278.54 199.46 181.32 76 184.86 319.09 224.87 204.42 167.19 284.75 203.37 184.88 77 188.21 325.77 229.04 208.22 170.21 290.80 207.15 188.32 78 191.02 331.27 232.44 211.31 172.76 295.76 210.23 191.11 79 193.67 336.74 235.92 214.47 175.15 300.71 213.37 193.97 80 196.47 342.13 239.30 217.55 177.69 305.60 216.43 196.75 81 199.20 347.77 242.78 220.71 180.17 310.71 219.57 199.61 82 201.93 353.17 246.16 223.78 182.62 315.57 222.63 202.39 83 204.34 357.95 249.16 226.51 184.80 319.91 225.35 204.86 84 206.62 362.64 252.09 229.17 186.86 324.14 227.99 207.27 85 208.87 367.25 255.00 231.82 188.90 328.31 230.63 209.66 86 211.21 371.94 257.92 234.47 191.02 332.56 233.26 212.06 87 213.55 376.81 261.00 237.27 193.13 336.97 236.05 214.59 88 217.53 383.42 265.11 241.01 196.72 342.95 239.77 217.97 89 220.71 390.03 269.28 244.80 199.62 348.91 243.55 221.41 90 223.99 396.64 273.39 248.54 202.58 354.89 247.25 224.77 91 227.18 403.58 277.72 252.48 205.46 361.18 251.18 228.34 92 230.23 410.04 281.76 256.15 208.22 367.01 254.82 231.66 93 + 277.18 504.36 340.84 309.86 250.67 452.32 308.25 280.23 Age* * Age as of the date the plan is issued. (see next page for Table 2) 7

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan. Find Your Premium Table 2 For Tobacco Users If you have used tobacco products in the past 12 months, use this table. Area 1 Male Female Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N < 65 $133.63 $239.44 $216.28 $147.53 $133.63 $239.44 $216.28 $147. 53 65 126.73 198.44 152.33 138.48 114.58 175.12 137.72 125.20 66 138.67 220.89 166.34 151.22 125.41 195.48 150.44 136.76 67 141.64 227.45 170.48 154.98 128.10 201.42 154.17 140.16 68 145.06 234.35 174.81 158.91 131.19 207.66 158.09 143.72 69 148.69 241.55 179.28 162.98 134.47 214.17 162.14 147.40 70 152.61 249.63 184.35 167.59 138.02 221.49 166.72 151.57 71 156.31 256.85 188.92 171.74 141.37 228.01 170.85 155.32 72 159.87 264.38 193.62 176.02 144.58 234.82 175.11 159.19 73 163.00 270.71 197.60 179.63 147.42 240.54 178.71 162.46 74 166.21 277.03 201.49 183.17 150.31 246.26 182.23 165.66 75 169.17 283.35 205.47 186.79 153.00 251.97 185.82 168.93 76 172.22 289.75 209.50 190.45 155.76 257.76 189.47 172.25 77 175.34 295.97 213.39 193.99 158.58 263.39 193.00 175.45 78 177.96 301.09 216.55 196.87 160.95 268.02 195.86 178.05 79 180.43 306.19 219.79 199.81 163.18 272.62 198.78 180.71 80 183.04 311.21 222.95 202.68 165.54 277.18 201.63 183.30 81 185.59 316.47 226.19 205.63 167. 85 281.94 204.56 185.96 82 188.13 321.50 229.33 208.49 170.14 286.47 207.41 188.56 83 190.38 325.95 232.13 211.03 172.17 290.51 209.95 190.86 84 192.50 330.32 234.86 213.51 174.09 294.45 212.41 193.10 85 194.59 334.62 237.57 215.98 175.99 298.34 214.87 195.33 86 196.78 338.99 240.29 218.45 177.96 302.29 217.32 197.56 87 198.95 343.53 243.16 221.06 179.93 306.41 219.92 199.93 88 202.66 349.68 246.99 224.54 183.28 311.98 223.38 203.07 89 205.63 355.84 250.88 228.07 185.97 317.53 226.90 206.27 90 208.68 362.00 254.71 231.55 188.74 323.10 230.35 209.41 91 211.65 368.46 258.74 235.22 191.42 328.96 234.01 212.74 92 214.49 374.48 262.51 238.64 193.99 334.39 237.41 215.82 93 + 258.23 462.35 317.55 288.68 233.54 413.87 287.19 261.08 Age* * Age as of the date the plan is issued. (see next page for more areas) 8

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan. Find Your Premium Table 2 For Tobacco Users If you have used tobacco products in the past 12 months, use this table. Area 2 Male Female Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N < 65 $133.63 $239.44 $216.28 $147. 53 $133.63 $239.44 $216.28 $147. 5 3 65 134.54 213.43 161.71 147. 01 121.64 188.67 146.21 132.92 66 147. 21 237.26 176.59 160.54 133.14 210.29 159.71 145.19 67 150.37 244.23 180.98 164.53 136.00 216.59 163.67 148.79 68 154.00 251.55 185.58 168.71 139.27 223.22 167. 84 152.58 69 157. 85 259.19 190.33 173.03 142.76 230.12 172.13 156.48 70 162.02 267.78 195.71 177.91 146.52 237.90 177.00 160.90 71 165.94 275.44 200.56 182.33 150.08 244.82 181.38 164.89 72 169.72 283.43 205.56 186.87 153.49 252.05 185.90 169.00 73 173.05 290.15 209.77 190.70 156.51 258.12 189.72 172.47 74 176.45 296.86 213.90 194.46 159.58 264.20 193.46 175.87 75 179.59 303.57 218.13 198.30 162.42 270.26 197.27 179.34 76 182.84 310.36 222.41 202.19 165.36 276.40 201.15 182.86 77 186.15 316.97 226.54 205.94 168.35 282.39 204.89 186.26 78 188.93 322.41 229.90 209.00 170.87 287.29 207.93 189.02 79 191.55 327.82 233.34 212.12 173.24 292.19 211.03 191.85 80 194.32 333.15 236.69 215.17 175.74 297.02 214.06 194.60 81 197.03 338.73 240.13 218.30 178.20 302.07 217.16 197.42 82 199.72 344.07 243.47 221.33 180.63 306.88 220.19 200.17 83 202.11 348.80 246.44 224.03 182.78 311.17 222.89 202.62 84 204.36 353.44 249.33 226.67 184.82 315.35 225.50 205.00 85 206.58 358.00 252.21 229.29 186.83 319.49 228.11 207.37 86 208.90 362.64 255.10 231.91 188.93 323.68 230.71 209.74 87 211.21 367.46 258.15 234.68 191.02 328.05 233.47 212.25 88 215.15 373.99 262.21 238.37 194.57 333.96 237.14 215.59 89 218.30 380.53 266.34 242.13 197.4 3 339.86 240.88 218.99 90 221.54 387.07 270.40 245.82 200.37 345.77 244.55 222.31 91 224.70 393.92 274.69 249.72 203.22 351.99 248.43 225.85 92 2 27.71 400.31 278.68 253.35 205.95 3 57.75 252.04 229.12 93 + 274.15 493.60 337.12 306.47 247.93 442.14 304.88 277.17 Age* * Age as of the date the plan is issued. (see next page for more areas) 9

Finding Your Monthly Premium Plans A, G & N Effective January 1, 2018 Plan F Effective May 1, 2018 Premiums are subject to change. Premium is based upon your tobacco usage, age, area, gender and plan. Find Your Premium Table 2 For Tobacco Users If you have used tobacco products in the past 12 months, use this table. Area 3 Male Female Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N < 65 $133.63 $239.44 $216.28 $147. 53 $133.63 $239.44 $216.28 $147. 5 3 65 152.35 247.62 183.12 166.47 137.75 219.57 165.56 150.51 66 166.70 274.60 199.97 181.79 150.76 244.06 180.85 164.41 67 170.28 282.49 204.94 186.31 154.00 251.20 185.34 168.49 68 174.39 290.78 210.14 191.04 157.71 258.70 190.05 172.78 69 178.75 299.44 215.53 195.93 161.66 266.52 194.92 177.20 70 183.47 309.16 221.61 201.47 165.92 275.32 200.43 182.21 71 187. 91 317. 8 4 227.11 206.46 169.95 283.16 205.39 186.72 72 192.18 326.88 232.77 211.61 173.81 291.35 210.51 191.37 73 195.96 334.49 237.54 215.95 177.23 298.23 214.83 195.30 74 199.81 342.09 242.22 220.20 180.70 305.10 219.07 199.15 75 203.37 349.69 247. 01 224.55 183.93 311.96 223.39 203.08 76 207.04 357.38 251.85 228.95 187.25 318.92 227.78 207.07 77 210.79 364.87 256.53 233.21 190.64 325.70 232.01 210.92 78 213.94 371.02 260.33 236.67 193.49 331.25 235.45 214.05 79 216.91 377.14 264.23 240.21 196.17 336.80 238.97 217.24 80 220.04 383.18 268.02 243.66 199.01 342.27 242.40 220.36 81 223.11 389.50 271.92 247.20 201.79 347.99 245.91 223.56 82 226.16 395.55 275.70 250.63 204.54 353.44 249.34 226.67 83 228.86 400.91 279.06 253.69 206.98 358.30 252.39 229.45 84 231.42 406.16 282.34 256.67 209.28 363.03 255.35 232.14 85 233.93 411.32 285.60 259.64 211.56 367.71 258.30 234.82 86 236.56 416.57 288.87 262.61 213.94 372.46 261.25 237.50 87 239.17 422.03 292.32 265.75 216.31 377.41 264.38 240.34 88 243.63 429.43 296.92 269.93 220.33 384.10 268.54 244.13 89 247.19 436.84 301.60 274.18 223.57 390.78 272.77 247.98 90 250.87 444.24 306.20 278.36 226.89 397.48 276.92 251.74 91 254.44 452.00 311.05 282.77 230.12 404.52 281.32 255.74 92 257.86 459.24 315.58 286.89 233.21 411.05 285.40 259.46 93 + 310.44 564.88 381.75 347.0 4 280.75 506.60 345.24 313.86 Age* * Age as of the date the plan is issued. 10

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, 2018. 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. 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. 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. 11

KY ONLY will need to place the extra disclaimer: (1 Plan A is not available as a Select Plan option.) Plan A Medicare (Part A) Hospital Services Per Benefit Period First 60 days All but $1,340 $1,340 (Part A deductible) 61 st thru 90 th day All but $335 a day $335 a day 91 st day and after: While using 60 lifetime reserve days All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days 101 st day and after Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies Beyond the additional 365 days 100% of Medicare eligible expenses ** 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 $167.50 a day Up to $167.50 a day Blood All costs 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/ 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. ** 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. 12

KY ONLY will need to place the extra disclaimer: (1 Plan A is not available as a Select Plan option.) Plan A Medicare (Part B) Medical Services Per Calendar Year 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 $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Generally 80% Generally 20% $183 (Part B deductible) Part B Excess Charges Above Medicare Approved Amounts All costs Blood First 3 pints All costs Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Clinical Laboratory Services 80% 20% Tests for Diagnostic Services 100% $183 (Part B deductible) Parts A & B Services Home Health Care Medicare Approved Services Medically necessary skilled care services 100% and medical supplies Durable medical equipment: First $183 of Medicare approved amounts* Remainder of Medicare approved amounts 80% 20% $183 (Part B deductible) * Once you have been billed $183 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. 13

Plan F Medicare (Part A) Hospital Services Per Benefit Period First 60 days All but $1,340 $1,340 (Part A deductible) 61 st thru 90 th day All but $335 a day $335 a day 91 st day and after: While using 60 lifetime reserve days All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days 101 st day and after Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies Beyond the additional 365 days 100% of Medicare eligible expenses ** 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 th 21 st thru 100 day All but $167.50 a day Up to $167.50 a day Blood All costs First 3 pints Additional amounts 100% 3 pints 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. ** 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. 14

Plan F Medicare (Part B) Medical Services Per Calendar Year 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 $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $183 (Part B deductible) Generally 80% Generally 20% Part B Excess Charges Above Medicare Approved Amounts 100% Blood First 3 pints All costs Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Clinical Laboratory Services $183 (Part B deductible) 80% 20% Tests for Diagnostic Services 100% Parts A & B Services Home Health Care Medicare Approved Services Medically necessary skilled care services and medical 100% supplies Durable medical equipment: First $183 of Medicare Approved Amounts* Remainder of Medicare approved amounts $183 (Part B deductible) 80% 20% * Once you have been billed $183 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. 15

Plan F 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 $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 16

Plan G Medicare (Part A) Hospital Services Per Benefit Period First 60 days All but $1,340 $1,340 (Part A deductible) 61 st thru 90 th day All but $335 a day $335 a day 91 st day and after: While using 60 lifetime reserve days All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days thru 100 th day 101 st day and after Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies Beyond the additional 365 days All but $167.50 a day 100% of Medicare eligible expenses Up to $167.50 a day ** 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 Blood All costs 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/ 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. ** 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. 17

Plan G Medicare (Part B) Medical Services Per Calendar Year 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 $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Generally 80% Generally 20% $183 (Part B deductible) Part B Excess Charges Above Medicare Approved Amounts 100% Blood First 3 pints All costs Next $183 of Medicare Approved Amounts* $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% Clinical Laboratory Services Tests for Diagnostic Services 100% Parts A & B Services Home Health Care Medicare Approved Services Medically necessary skilled care services and medical 100% supplies Durable medical equipment: First $183 of Medicare Approved Amounts* Remainder of Medicare approved amounts 80% 20% $183 (Part B deductible) * Once you have been billed $183 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. 18

Plan G 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 $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 19

Plan N Medicare (Part A) Hospital Services Per Benefit Period First 60 days All but $1,340 $1,340 (Part A deductible) 61 st thru 90 th day All but $335 a day $335 a day 91 st day and after: While using 60 lifetime reserve days All but $670 a day $670 a day Once lifetime reserve days are used: Additional 365 days 21 st thru 100 th day 101 st day and after Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies Beyond the additional 365 days All but $167.50 a day 100% of Medicare eligible expenses Up to $167.50 a day ** 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 Blood All costs 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/ 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. ** 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. 20

Plan N Medicare (Part B) Medical Services Per Calendar Year 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 $183 of Medicare Approved Amounts* $183 (Part B deductible) Remainder of Medicare Generally 80% Balance, other than Up to $20 per Approved Amounts 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. 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. Part B Excess Charges Above Medicare Approved Amounts All costs Blood First 3 pints All costs Next $183 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Clinical Laboratory Services 80% 20% Tests for Diagnostic Services 100% $183 (Part B deductible) * Once you have been billed $183 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. 21

Plan N Parts A & B Services Home Health Care Medicare Approved Services Medically necessary skilled care services and 100% medical supplies Durable medical equipment: First $183 of Medicare approved amounts* Remainder of Medicare approved amounts 80% 20% $183 (Part B deductible) 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 $250 each calendar year $250 80% to a lifetime 20% and amounts Remainder of Charges maximum benefit over the $50,000 of $50,000 lifetime maximum * Once you have been billed $183 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. 22

P.O. Box 659816 San Antonio, TX 78265-9116 In Missouri (excluding the 30 counties in the Kansas City area), Anthem Blue Cross and Blue Shield is the trade name of Healthy Alliance Life Insurance Company (HALIC) and Anthem Insurance Companies, Inc. (AICI). Plans A, G & N are offered by HALIC. Plan F is offered by AICI. 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. 2018 OOC-MO (DUAL)_(Rev. 03/2018)

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