California Anthem Blue Cross Freedom Blue PPO Plans

Summary of Benefits
SM
for Freedom Blue Plan I (Regional
SM
PPO) and Freedom Blue Plus
(Regional PPO)

Available in California

A health plan with a Medicare contract.

In California, Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the
Blue Cross Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ®The
Blue Cross names and symbols are registered marks of the Blue Cross Association.

M0013_10SB_004_R9943_001_003 SCASB2286BM 1009
09/29/2009_FINAL CA

Section I: Introduction to the Summary
of Benefits
Thank you for your interest in Freedom Blue Plan I (Regional PPO) and Freedom Blue Plus (Regional
PPO). Our plans are offered by Anthem Blue Cross Life and Health Insurance Company (Anthem Blue
Cross Life and Health Insurance Company), a Medicare Advantage Preferred Provider Organization (PPO).
This Summary of Benefits tells you some features of our plans. It doesn’t list every service that we cover or
list every limitation or exclusion. To get a complete list of our benefits, please call Freedom Blue Plan I
(Regional PPO) or Freedom Blue Plus (Regional PPO) and ask for the “Evidence of Coverage.”

You Have Choices in Your Our members receive all of the benefits that the
Original Medicare plan offers. We also offer more
Health Care benefits, which may change from year to year.
As a Medicare beneficiary, you can choose from
different Medicare options. One option is the
Original (fee-for-service) Medicare plan. Another
Where Are Freedom Blue Plan
option is a Medicare health plan, like Freedom I (Regional PPO) and Freedom
Blue Plan I (Regional PPO) or Freedom Blue Plus Blue Plus (Regional PPO)
(Regional PPO). You may have other options too.
You make the choice. No matter what you decide, Available?
you are still in the Medicare program.
The service area for these plans includes the
You may be able to join or leave a plan only at following counties:
certain times. Please call Freedom Blue Plan I
(Regional PPO) or Freedom Blue Plus (Regional California: Alameda, Alpine, Amador, Butte,
PPO) at the number listed at the end of this Calaveras, Colusa, Contra Costa, Del Norte,
introduction or 1-800-MEDICARE Eldorado, Fresno, Glenn, Humboldt, Imperial,
(1-800-633-4227) for more information. Inyo, Kern, Kings, Lake, Lassen, Los Angeles,
TTY/TDD users should call Madera, Marin, Mariposa, Mendocino, Merced,
1-877-486-2048. You can call this number Modoc, Mono, Monterey, Napa, Nevada,
24 hours a day, 7 days a week. Orange, Placer, Plumas, Riverside, Sacramento,
San Benito, San Bernardino, San Diego, San
Francisco, San Joaquin, San Luis Obispo, San
How Can I Compare My Mateo, Santa Barbara, Santa Clara, Santa Cruz,
Shasta, Sierra, Siskiyou, Solano, Sonoma,
Options? Stanislaus, Sutter, Tehama, Trinity, Tulare,
You can compare Freedom Blue Plan I (Regional Tuolumne, Ventura, Yolo and Yuba counties.
PPO) and Freedom Blue Plus (Regional PPO) You must live in one of these areas to join the
and the Original Medicare plan using this plan.
Summary of Benefits. The charts in this booklet
list some important health benefits. For each There is more than one plan listed in this
benefit, you can see what our plan covers and Summary of Benefits. If you are enrolled in one
what the Original Medicare plan covers. plan and wish to switch to another plan, you may
do so only during certain times of the year. Please
call Customer Service for more information.

Page 1 – Freedom Blue Plan I (Regional PPO) and Freedom Blue Plus (Regional PPO)
Summary of Benefits – SCASB2286BM

Who Is Eligible to Join Does My Plan Cover Medicare
Freedom Blue Plan I (Regional Part B or Part D Drugs?
PPO) or Freedom Blue Plus Freedom Blue Plan I (Regional PPO) and
(Regional PPO)? Freedom Blue Plus (Regional PPO) do cover both
Medicare Part B prescription drugs and Medicare
You can join Freedom Blue Plan I (Regional Part D prescription drugs.
PPO) or Freedom Blue Plus (Regional PPO) if
you are entitled to Medicare Part A and enrolled
in Medicare Part B and live in the service area. Where Can I Get My
However, individuals with end-stage renal disease Prescriptions If I Join This
are generally not eligible to enroll in Freedom
Blue Plan I (Regional PPO) or Freedom Blue Plus Plan?
(Regional PPO) unless they are members of our
organization and have been since their dialysis Freedom Blue Plan I (Regional PPO) and
began. Freedom Blue Plus (Regional PPO) have formed a
network of pharmacies. You must use a network
pharmacy to receive plan benefits. We may not
Can I Choose My Doctors? pay for your prescriptions if you use an out-of-
network pharmacy, except in certain cases.
Freedom Blue Plan I (Regional PPO) and
Freedom Blue Plus (Regional PPO) have formed a The pharmacies in our network can change at any
network of doctors, specialists, and hospitals. You time. You can ask for a pharmacy directory or
can use any doctor who is part of our network. visit us at www.anthem.com/medicare. Our
You may also go to doctors outside of our customer service number is listed at the end of
network. The health providers in our network can this introduction.
change at any time. Freedom Blue Plan I (Regional PPO) and
You can ask for a current Provider Directory or Freedom Blue Plus (Regional PPO) have a list of
for an up-to-date list visit us at our website. preferred pharmacies. At these pharmacies, you
may get your drugs at a lower copay or
Our customer service number is listed at the end coinsurance. You may go to a non-preferred
of this introduction. pharmacy, but you may have to pay more for your
prescription drugs.

What Happens If I Go to a
Doctor Who’s Not in Your What Is a Prescription Drug
Network? Formulary?
Freedom Blue Plan I (Regional PPO) and
You can go to doctors, specialists, or hospitals in
Freedom Blue Plus (Regional PPO) use a
or out of network. You may have to pay more for
formulary. A formulary is a list of drugs covered
the services you receive outside the network, and
by your plan to meet patient needs. We may
you may have to follow special rules prior to
periodically add, remove, or make changes to
getting services in and/or out of network. For
coverage limitations on certain drugs or change
more information, please call the customer service
how much you pay for a drug. If we make any
number at the end of this introduction.
formulary change that limits our members’ ability
to fill their prescriptions, we will notify the
affected enrollees before the change is made. We
will send a formulary to you, and you can see our


complete formulary on our website at appeal if we deny coverage for an item or service,
www.anthem.com/medicare. and the right to file a grievance.
If you are currently taking a drug that is not on You have the right to request an organization
our formulary or subject to additional determination if you want us to provide or pay for
requirements or limits, you may be able to get a an item or service that you believe should be
temporary supply of the drug. You can contact us covered.
to request an exception or switch to an alternative
drug listed on our formulary with your physician’s If we deny coverage for your requested item or
help. Call us to see if you can get a temporary service, you have the right to appeal and ask us to
supply of the drug or for more details about our review our decision.
drug transition policy. You may ask us for an expedited (fast) coverage
determination or appeal if you believe that
waiting for a decision could seriously put your life
How Can I Get Extra Help or health at risk, or affect your ability to regain
With My Prescription Drug maximum function. If your doctor makes or
supports the expedited request, we must expedite
Plan Costs? our decision.
You may be able to get extra help to pay for your Finally, you have the right to file a grievance with
prescription drug premiums and costs. To see if us if you have any type of problem with us or one
you qualify for getting extra help, call: of our network providers that does not involve
coverage for an item or service.
 1-800-MEDICARE (1-800-633-4227).
TTY/TDD users should call 1-877-486-2048, If your problem involves quality of care, you also
24 hours a day/7 days a week; have the right to file a grievance with the Quality
 The Social Security Administration at Improvement Organization (QIO) for your state:
1-800-772-1213 between 7 a.m. and 7 p.m., Lumetra Health Services Advisory Group
Monday through Friday. TTY/TDD users 1-800-841-1602
should call 1-800-325-0778; or
As a member of Freedom Blue Plan I (Regional
 Your State Medicaid Office. PPO) or Freedom Blue Plus (Regional PPO) you
have the right to request a coverage
What Are My Protections in determination, which includes the right to request
an exception, the right to file an appeal if we deny
This Plan? coverage for a prescription drug, and the right to
All Medicare Advantage plans agree to stay in the file a grievance.
program for a full year at a time. Each year, the You have the right to request a coverage
plans decide whether to continue for another year. determination if you want us to cover a Part D
Even if a Medicare Advantage plan leaves the drug that you believe should be covered.
program, you will not lose Medicare coverage. If a An exception is a type of coverage determination.
plan decides not to continue, it must send you a You may ask us for an exception if you believe
letter at least 60 days before your coverage will you need a drug that is not on our list of covered
end. The letter will explain your options for drugs or believe you should get a non-preferred
Medicare coverage in your area. drug at a lower out-of-pocket cost.
As a member of Freedom Blue Plan I (Regional You can also ask for an exception to cost
PPO) or Freedom Blue Plus (Regional PPO), you utilization rules, such as a limit on the quantity of
have the right to request an organization a drug.
determination, which includes the right to file an


If you think you need an exception, you should person (who could be the patient) under doctor
contact us before you try to fill your prescription supervision.
at a pharmacy. Your doctor must provide a  Osteoporosis Drugs: Injectable drugs for
statement to support your exception request. osteoporosis for certain women with Medicare.
If we deny coverage for your prescription drug(s),  Erythropoietin (Epoetin Alfa or Epogen®): By
you have the right to appeal and ask us to review injection if you have end-stage renal disease
our decision. (permanent kidney failure requiring either
Finally, you have the right to file a grievance if dialysis or transplantation) and need this drug to
you have any type of problem with us or one of treat anemia.
our network pharmacies that does not involve  Hemophilia Clotting Factors: Self-administered
coverage for a prescription drug. clotting factors if you have hemophilia.
If your problem involves quality of care, you also  Injectable Drugs: Most injectable drugs
have the right to file a grievance with the Quality administered incident to a physician’s service.
Improvement Organization (QIO) for your state:  Immunosuppressive Drugs: Immunosuppressive
Lumetra Health Services Advisory Group drug therapy for transplant patients if the
1-800-841-1602 transplant was paid for by Medicare, or paid by
a private insurance that paid as a primary payer
to your Medicare Part A coverage, in a
What Is a Medication Therapy Medicare-certified facility.
Management (MTM) Program?  Some Oral Cancer Drugs: If the same drug is
available in injectable form.
A Medication Therapy Management (MTM)
program is a free service we may offer. You may  Oral Anti-Nausea Drugs: If you are part of an
be invited to participate in a program designed for anti-cancer chemotherapeutic regimen.
your specific health and pharmacy needs. You  Inhalation and Infusion Drugs provided through
may decide not to participate, but it is DME.
recommended that you take full advantage of this
covered service if you are selected. Contact
Freedom Blue Plan I (Regional PPO) or Freedom Plan Ratings
Blue Plus (Regional PPO) for more details. The Medicare program rates how well plans
perform in different categories (for example,
detecting and preventing illness, ratings from
What Types of Drugs May patients and customer service).
Be Covered Under Medicare If you have access to the Web, you may use the
Part B? Web tools on www.medicare.gov and select
“Compare Medicare Prescription Drug Plans” or
Some outpatient prescription drugs may be
“Compare Health Plans and Medigap Policies in
covered under Medicare Part B. These may
Your Area” to compare the plan ratings for
include, but are not limited to, the following
Medicare plans in your area.
types of drugs. Contact Freedom Blue Plan I
(Regional PPO) or Freedom Blue Plus (Regional You can also call us directly at 1-877-811-3107 to
PPO) for more details. obtain a copy of the plan ratings for this plan.
TTY users call 1-877-247-1657.
 Some Antigens: If they are prepared by a doctor
and administered by a properly instructed


Please Call Anthem Blue Cross Life and Health Insurance
Company for More Information About Freedom Blue Plan I
(Regional PPO) and Freedom Blue Plus (Regional PPO)
 Visit us at www.anthem.com/medicare or call  Prospective members should call, locally,
us: 1-888-211-9813
(TTY/TDD: 1-800-241-6894).
 Customer Service Hours: 8 a.m. to 8 p.m.,
7 days a week  For more information about Medicare, please
call Medicare at 1-800-MEDICARE
 Current members should call, toll free,
(1-800-633-4227). TTY users should call
1-877-811-3107
1-877-486-2048. You can call 24 hours a day,
(TTY/TDD: 1-877-247-1657).
7 days a week.
 Prospective members should call, toll free,
 Or, visit www.medicare.gov on the Web.
1-888-211-9813
(TTY/TDD: 1-800-241-6894).  If you have special needs, this document may be
available in other formats.
 Current members should call, locally,
1-877-811-3107
(TTY/TDD: 1-877-247-1657).


If you have any questions about this plan’s benefits or costs, please contact Anthem Blue Cross Life
and Health Insurance Company for details.

Section II: Summary of Benefits
Benefit Original Medicare Freedom Blue Freedom Blue Plus
Plan I (Regional (Regional PPO)
PPO)

Important Information

1. In 2009 the monthly Part General General
Premium and B Premium was $96.40
Other and will change for 2010
Important and the yearly Part B $0 monthly plan $31 monthly plan
Information deductible amount was premium in addition to premium in addition to
$135 and will change for your monthly Medicare your monthly Medicare
2010. Part B premium. Part B premium.
If a doctor or supplier does
not accept assignment,
their costs are often higher,
which means you pay
more. In-Network In-Network
Most people will pay the $3,350 out-of-pocket limit. $3,350 out-of-pocket limit.
standard monthly Part B All plan services included. All plan services included.
premium. However,
starting January 1, 2010, In and Out-of- In and Out-of-
some people will pay a
higher premium because of Network Network
their yearly income. (For $500 yearly deductible. $500 yearly deductible.
2009, this amount was Contact the plan for Contact the plan for
$85,000 for singles, services that apply. services that apply.
$170,000 for married $3,350 out-of-pocket limit. $3,350 out-of-pocket limit.
couples. This amount may
change for 2010.) For In-Network: In-Network:
more information about This limit includes only This limit includes only
Part B premiums based on Medicare-covered services. Medicare-covered services.
income, call Social Security Out-of-Network: Out-of-Network:
at 1-800-772-1213. TTY
users should call 1-800- This limit includes only This limit includes only
325-0778. Medicare-covered services. Medicare-covered services.


PPO)
2. You may go to any doctor, In-Network In-Network
Doctor and specialist or hospital that No referral required for No referral required for
Hospital Choice accepts Medicare. network doctors, network doctors,
specialists, and hospitals. specialists, and hospitals.
(For more
information, see Out-of-Network Out-of-Network
Emergency - #15
and Urgently Plan covers you when you Plan covers you when you
travel in the U.S. travel in the U.S.
Needed Care -
#16.)

Summary of Benefits

Inpatient Care

3. In 2009 the amounts for In-Network In-Network
Inpatient each benefit period were: $850 copay for each $850 copay for each
Hospital Care  Days 1 - 60: $1,068 Medicare-covered hospital Medicare-covered hospital
deductible stay stay
(includes $0 copay for additional $0 copay for additional
 Days 61 - 90: $267 per
Substance Abuse hospital days hospital days
day
and No limit to the number of No limit to the number of
Rehabilitation  Days 91 - 150: $534 per days covered by the plan days covered by the plan
Services) lifetime reserve day each benefit period. each benefit period.
These amounts will change Except in an emergency, Except in an emergency,
for 2010. your doctor must tell the your doctor must tell the
Call 1-800-MEDICARE plan that you are going to plan that you are going to
(1-800-633-4227) for be admitted to the hospital. be admitted to the hospital.
information about lifetime
reserve days.
Out-of-Network Out-of-Network
Lifetime reserve days can
only be used once. 15% of the cost for each 15% of the cost for each
hospital stay. hospital stay.
A “benefit period” starts
the day you go into a
hospital or skilled nursing
facility. It ends when you
go for 60 days in a row
without hospital or skilled
nursing care. If you go into
the hospital after one
benefit period has ended, a


PPO)
new benefit period begins.
You must pay the inpatient
hospital deductible for each
benefit period. There is no
limit to the number of
benefit periods you can
have.

4. Same deductible and copay In-Network In-Network
Inpatient as inpatient hospital care $850 copay for each $850 copay for each
Mental Health (see “Inpatient Hospital Medicare-covered hospital Medicare-covered hospital
Care Care” above). stay. stay.
190-day lifetime limit in a You get up to 190 days in a You get up to 190 days in a
psychiatric hospital. psychiatric hospital in a psychiatric hospital in a
lifetime. lifetime.
Except in an emergency, Except in an emergency,
your doctor must tell the your doctor must tell the
plan that you are going to plan that you are going to
be admitted to the hospital. be admitted to the hospital.

15% of the cost for each 15% of the cost for each
hospital stay. hospital stay.

5. In 2009 the amounts for General General
Skilled Nursing each benefit period after at Authorization rules may Authorization rules may
Facility (SNF) least a 3-day covered apply. apply.
hospital stay were:
(in a Medicare-  Days 1 - 20: $0 per day In-Network In-Network
certified skilled
 Days 21 - 100: $133.50 For SNF stays: For SNF stays:
nursing facility)
per day
 Days 1 - 20: $0 copay per  Days 1 - 20: $0 copay per
These amounts will change day day
for 2010.
100 days for each benefit  Days 21 - 100: $130  Days 21 - 100: $130
period. copay per day copay per day
A “benefit period” starts Plan covers up to 100 days Plan covers up to 100 days
the day you go into a each benefit period each benefit period
hospital or SNF. It ends No prior hospital stay is No prior hospital stay is
when you go for 60 days in required. required.
a row without hospital or
skilled nursing care. If you
go into the hospital after


PPO)
one benefit period has Out-of-Network Out-of-Network
ended, a new benefit
period begins. You must 30% of the cost for each 30% of the cost for each
pay the inpatient hospital SNF stay. SNF stay.
deductible for each benefit
period. There is no limit to
the number of benefit
periods you can have.

6. $0 copay. General General
Home Health Authorization rules may Authorization rules may
Care apply. apply.

(includes In-Network In-Network
medically-
necessary $0 copay for each $0 copay for each
intermittent Medicare-covered home Medicare-covered home
health visit. health visit.
skilled nursing
care, home health
aide services, and Out-of-Network Out-of-Network
rehabilitation 30% for home health visits. 30% for home health visits.
services, etc.)

7. You pay part of the cost for General General
Hospice outpatient drugs and You must get care from a You must get care from a
inpatient respite care. Medicare-certified hospice. Medicare-certified hospice.
You must get care from a
Medicare-certified hospice.

Outpatient Care

8. 20% coinsurance General General
Doctor Office See “Physical Exams” for See “Physical Exams” for
Visits more information. more information.

In-Network In-Network
$15 copay for each primary $10 copay for each primary
care doctor visit for care doctor visit for
Medicare-covered benefits. Medicare-covered benefits.
$35 copay for each in-area, $35 copay for each in-area,
network urgent care network urgent care


PPO)
Medicare-covered visit. Medicare-covered visit.
$25 copay for each $25 copay for each
specialist visit for specialist visit for
Medicare-covered benefits. Medicare-covered benefits.

$30 copay for each primary $25 copay for each primary
care doctor visit. care doctor visit.
specialist visit. specialist visit.

9. Routine care not covered General General
Chiropractic 20% coinsurance for Authorization rules may Authorization rules may
Services manual manipulation of apply. apply.
the spine to correct
subluxation (a In-Network In-Network
displacement or
misalignment of a joint or $25 copay for each $25 copay for each
body part) if you get it Medicare-covered visit. Medicare-covered visit.
from a chiropractor or Medicare-covered $20 copay for up to 20
other qualified providers. chiropractic visits are for routine visit(s) every year
manual manipulation of Medicare-covered
the spine to correct chiropractic visits are for
subluxation (a manual manipulation of
displacement or the spine to correct
misalignment of a joint or subluxation (a
body part) if you get it displacement or
from a chiropractor or misalignment of a joint or
other qualified providers. body part) if you get it
from a chiropractor or
Out-of-Network other qualified providers.
30% of the cost for
chiropractic benefits. Out-of-Network
30% to 50% of the cost for
chiropractic benefits.

10. Routine care not covered. In-Network In-Network
Podiatry 20% coinsurance for $25 copay for each $25 copay for each
Services medically necessary foot Medicare-covered visit. Medicare-covered visit.
care, including care for Medicare-covered podiatry Medicare-covered podiatry
medical conditions benefits are for medically- benefits are for medically-
affecting the lower limbs. necessary foot care. necessary foot care.


PPO)
30% of the cost for 30% of the cost for
podiatry benefits. podiatry benefits.

11. 45% coinsurance for most General General
Outpatient outpatient mental health Authorization rules may Authorization rules may
Mental Health services. apply. apply.
Care
Medicare-covered Medicare-covered
individual or group therapy individual or group therapy
visit. visit.

30% of the cost for mental 30% of the cost for mental
health benefits. health benefits.
30% of the cost for mental 30% of the cost for mental
health benefits with a health benefits with a
psychiatrist. psychiatrist.

Outpatient Authorization rules may Authorization rules may
Substance Abuse apply. apply.
Care
$40 copay for Medicare- $40 copay for Medicare-
covered individual or covered individual or
group visits. group visits.

outpatient substance abuse outpatient substance abuse
benefits. benefits.

13. 20% coinsurance for the General General
Outpatient doctor Authorization rules may Authorization rules may
Services/ 20% of outpatient facility apply. apply.
Surgery charges


PPO)
ambulatory surgical center ambulatory surgical center
visit. visit.
$25 to $250 copay for each $25 to $200 copay for each
outpatient hospital facility outpatient hospital facility
visit. visit.

ambulatory surgical center ambulatory surgical center
benefits. benefits.
outpatient hospital facility outpatient hospital facility
benefits. benefits.

Ambulance Authorization rules may Authorization rules may
Services apply. apply.

(medically- In-Network In-Network
necessary $175 copay for Medicare- $100 copay for Medicare-
ambulance covered ambulance covered ambulance
services) benefits. benefits.

$175 copay for ambulance $100 copay for ambulance
benefits. benefits.

15. 20% coinsurance for the General General
Emergency Care doctor $50 copay for Medicare- $50 copay for Medicare-
20% of facility charge, or a covered emergency room covered emergency room
(You may go to set copay per emergency visits. visits.
any emergency room visit Worldwide coverage. Worldwide coverage.
room if you You don’t have to pay the If you are admitted to the If you are admitted to the
reasonably emergency room copay if hospital within 72-hour(s) hospital within 72-hour(s)
believe you need you are admitted to the for the same condition, you for the same condition, you
emergency care.) hospital for the same pay $0 for the emergency pay $0 for the emergency
condition within 3 days of room visit room visit


PPO)
the emergency room visit.
NOT covered outside the
U.S. except under limited
circumstances.

16. 20% coinsurance, or a set General General
Urgently copay $35 copay for Medicare- $35 copay for Medicare-
Needed Care NOT covered outside the covered urgently needed covered urgently needed
U.S. except under limited care visits. care visits.
(This is NOT circumstances. If you are admitted to the If you are admitted to the
emergency care, hospital within 72-hour(s) hospital within 72-hour(s)
and in most cases, for the same condition, $0 for the same condition, $0
is out of the for the urgent-care visit. for the urgent-care visit.
service area.)

Outpatient Authorization rules may Authorization rules may
Rehabilitation apply. apply.
Services
(Occupational $25 to $50 copay for $25 to $50 copay for
Therapy, Physical Medicare-covered Medicare-covered
Therapy, Speech occupational therapy visits. occupational therapy visits.
and Language
Therapy) $25 to $50 copay for $25 to $50 copay for
Medicare-covered physical Medicare-covered physical
and/or speech/language and/or speech/language
therapy visits. therapy visits.

occupational therapy occupational therapy
benefits. benefits.
physical and/or physical and/or
speech/language therapy speech/language therapy
visits. visits.

Outpatient Medical Services and Supplies

Durable Authorization rules may Authorization rules may


PPO)
Medical apply. apply.
Equipment
(includes 20% of the cost for 20% of the cost for
wheelchairs, Medicare-covered items. Medicare-covered items.
oxygen, etc.)
30% of the cost for durable 30% of the cost for durable
medical equipment. medical equipment.

Prosthetic Authorization rules may Authorization rules may
Devices apply. apply.

(includes braces, In-Network In-Network
artificial limbs 20% of the cost for 20% of the cost for
and eyes, etc.) Medicare-covered items. Medicare-covered items.

prosthetic devices. prosthetic devices.

20. 20% coinsurance In-Network In-Network
Diabetes Self- Nutrition therapy is for $0 copay for diabetes self- $0 copay for diabetes self-
Monitoring people who have diabetes monitoring training. monitoring training.
Training, or kidney disease (but
$0 copay for nutrition $0 copay for nutrition
Nutrition aren’t on dialysis or haven’t
therapy for diabetes. therapy for diabetes.
Therapy, and had a kidney transplant)
when referred by a doctor. 20% of the cost for 20% of the cost for
Supplies diabetes supplies. diabetes supplies.
These services can be given
by a registered dietitian or Separate office visit cost Separate office visit cost
(includes include a nutritional sharing of $15 to $25 sharing of $10 to $25
coverage for assessment and counseling copay may apply. copay may apply.
glucose monitors, to help you manage your
test strips, diabetes or kidney disease. Out-of-Network Out-of-Network
lancets, screening
tests, and self- 30% of the cost for 30% of the cost for
management diabetes self-monitoring diabetes self-monitoring
training) training. training.
nutrition therapy for nutrition therapy for
diabetes. diabetes.


PPO)
diabetes supplies. diabetes supplies.

21. 20% coinsurance for General General
Diagnostic diagnostic tests and X-rays Authorization rules may Authorization rules may
Tests, X-Rays, $0 copay for Medicare- apply. apply.
Lab Services, covered lab services
and Radiology Lab Services: Medicare In-Network In-Network
Services covers medically-necessary
diagnostic lab services that $15 copay for Medicare- $10 copay for Medicare-
are ordered by your covered lab services. covered lab services.
treating doctor when they $25 to $150 copay for $25 to $100 copay for
are provided by a Clinical Medicare-covered Medicare-covered
Laboratory Improvement diagnostic procedures and diagnostic procedures and
Amendments (CLIA) tests. tests.
certified laboratory that $25 to $150 copay for $25 to $100 copay for
participates in Medicare. Medicare-covered X-rays. Medicare-covered X-rays.
Diagnostic lab services are
done to help your doctor $25 to $150 copay for $25 to $100 copay for
diagnose or rule out a Medicare-covered Medicare-covered
suspected illness or diagnostic radiology diagnostic radiology
condition. Medicare does services. services.
not cover most routine 20% of the cost for 20% of the cost for
screening tests, like Medicare-covered Medicare-covered
checking your cholesterol. therapeutic radiology therapeutic radiology
services. services.
Separate office visit cost Separate office visit cost
sharing of $15 to $25 may sharing of $10 to $25 may
apply. apply.

diagnostic procedures, diagnostic procedures,
tests, and lab services. tests, and lab services.
therapeutic radiology therapeutic radiology
services services
outpatient X-rays. outpatient X-rays.
$200 copay for diagnostic $150 copay for diagnostic
radiology services radiology services


PPO)

Preventive Services

Bone Mass Covered once every 24 $0 copay for Medicare- $0 copay for Medicare-
Measurement months (more often if covered bone mass covered bone mass
medically necessary) if you measurement measurement
(for people with meet certain medical Separate office visit cost Separate office visit cost
Medicare who are conditions. sharing of $15 to $25 may sharing of $10 to $25 may
at risk) apply. apply.

Medicare-covered bone Medicare-covered bone
mass measurement. mass measurement.

Colorectal Covered when you are high $0 copay for Medicare- $0 copay for Medicare-
Screening Exam risk or when you are age 50 covered colorectal covered colorectal
and older. screenings. screenings.
(for people with Separate office visit cost Separate office visit cost
Medicare age 50 sharing of $15 to $25 may sharing of $10 to $25 may
and older) apply. apply.

colorectal screenings. colorectal screenings.

24. $0 copay for flu and In-Network In-Network
Immunizations pneumonia vaccines $0 copay for flu and $0 copay for flu and
20% coinsurance for pneumonia vaccines. pneumonia vaccines.
(Flu vaccine, Hepatitis B vaccine $0 copay for Hepatitis B $0 copay for Hepatitis B
Hepatitis B You may only need the vaccine. vaccine.
vaccine - for pneumonia vaccine once in No referral needed for flu No referral needed for flu
people with your lifetime. Call your and pneumonia vaccines. and pneumonia vaccines.
Medicare who are doctor for more
at risk, information. Separate office visit cost Separate office visit cost
pneumonia sharing of $15 to $25 may sharing of $10 to $25 may
vaccine) apply. apply.
No referral needed for No referral needed for
other immunizations. other immunizations.


PPO)
$0 copay for $0 copay for
immunizations. immunizations.

Mammograms No referral needed. $0 copay for Medicare- $0 copay for Medicare-
(Annual Covered once a year for all covered screening covered screening
Screenings) women with Medicare age mammograms. mammograms.
40 and older. One baseline Separate office visit cost Separate office visit cost
(for women with mammogram covered for sharing of $15 to $25 may sharing of $10 to $25 may
Medicare age 40 women with Medicare apply. apply.
and older) between age 35 and 39.
screening mammograms. screening mammograms.

26. $0 copay for Pap smears In-Network In-Network
Pap Smears and Covered once every 2 years. $0 copay for Medicare- $0 copay for Medicare-
Pelvic Exams Covered once a year for covered Pap smears and covered Pap smears and
women with Medicare at pelvic exams. pelvic exams.
(for women with high risk. Separate office visit cost Separate office visit cost
Medicare) 20% coinsurance for pelvic sharing of $15 to $25 may sharing of $10 to $25 may
exams apply. apply.

30% of the cost for Pap 30% of the cost for Pap
smears and pelvic exams. smears and pelvic exams.

27. 20% coinsurance for the In-Network In-Network
Prostate Cancer digital rectal exam. $0 copay for Medicare- $0 copay for Medicare-
Screening $0 for the PSA test; 20% covered prostate cancer covered prostate cancer
Exams coinsurance for other screening screening
related services. Separate office visit cost Separate office visit cost
(for men with Covered once a year for all sharing of $15 to $25 may sharing of $10 to $25 may
Medicare age 50 men with Medicare over apply. apply.
and older) age 50.
prostate cancer screening. prostate cancer screening.


PPO)
28. 20% coinsurance for renal In-Network In-Network
End-Stage dialysis 10% of the cost for renal 10% of the cost for renal
Renal Disease 20% coinsurance for dialysis dialysis
nutrition therapy for end-
stage renal disease $0 copay for nutrition $0 copay for nutrition
Nutrition therapy is for therapy for end-stage renal therapy for end-stage renal
people who have diabetes disease disease
or kidney disease (but
aren’t on dialysis or haven’t
had a kidney transplant) Out-of-Network Out-of-Network
when referred by a doctor. 30% of the cost for 30% of the cost for
These services can be given nutrition therapy for end- nutrition therapy for end-
by a registered dietitian or stage renal disease. stage renal disease.
include a nutritional 10% of the cost for renal 10% of the cost for renal
assessment and counseling dialysis. dialysis.
to help you manage your
diabetes or kidney disease.

29. Most drugs are not covered Drugs Covered Drugs Covered
Prescription under Original Medicare.
Drugs You can add prescription Under Medicare Under Medicare
drug coverage to Original Part B Part B
Medicare by joining a
Medicare Prescription
Drug plan, or you can get General General
all your Medicare coverage, 20% of the cost for Part B- 20% of the cost for Part B-
including prescription drug covered chemotherapy covered chemotherapy
coverage, by joining a drugs and other Part B- drugs and other Part B-
Medicare Advantage plan covered drugs. covered drugs.
or a Medicare Cost plan 25% of the cost for Part B 25% of the cost for Part B
that offers prescription drugs out-of-network. drugs out-of-network.
drug coverage.
Drugs Covered Drugs Covered
Under Medicare Under Medicare
Part D Part D

General General
This plan uses a formulary. This plan uses a formulary.
The plan will send you the The plan will send you the
formulary. You can also see formulary. You can also see
the formulary at the formulary at


PPO)
www.anthem.com/ www.anthem.com/
medicare on the Web. medicare on the Web.
Different out-of-pocket Different out-of-pocket
costs may apply for people costs may apply for people
who who
 have limited incomes,  have limited incomes,
 live in long-term care  live in long-term care
facilities, or facilities, or
 have access to Indian /  have access to Indian /
Tribal / Urban (Indian Tribal / Urban (Indian
Health Service). Health Service).
The plan offers national in- The plan offers national in-
network prescription network prescription
coverage (i.e., this would coverage (i.e., this would
include 50 states and DC). include 50 states and DC).
This means that you will This means that you will
pay the same cost-sharing pay the same cost-sharing
amount for your amount for your
prescription drugs if you prescription drugs if you
get them at an in-network get them at an in-network
pharmacy outside of the pharmacy outside of the
plan’s service area (for plan’s service area (for
instance when you travel). instance when you travel).
Total yearly drug costs are Total yearly drug costs are
the total drug costs paid by the total drug costs paid by
both you and the plan. both you and the plan.
Some drugs have quantity Some drugs have quantity
limits. limits.
Your provider must get Your provider must get
prior authorization from prior authorization from
Freedom Blue Plan I Freedom Blue Plus
(Regional PPO) for certain (Regional PPO) for certain
drugs. drugs.
You must go to certain You must go to certain
pharmacies for a very pharmacies for a very
limited number of drugs, limited number of drugs,
due to special handling, due to special handling,
provider coordination, or provider coordination, or
patient education patient education
requirements for these requirements for these
drugs that cannot be met drugs that cannot be met
by most pharmacies in by most pharmacies in
your network. These drugs your network. These drugs
are listed on the plan’s are listed on the plan’s


PPO)
website, formulary, and website, formulary, and
printed materials, as well as printed materials, as well as
on the Medicare on the Medicare
Prescription Drug Plan Prescription Drug Plan
Finder on Finder on
www.medicare.gov. www.medicare.gov.
If the actual cost of a drug If the actual cost of a drug
is less than the normal is less than the normal
cost-sharing amount for cost-sharing amount for
that drug, you will pay the that drug, you will pay the
actual cost, not the higher actual cost, not the higher
cost-sharing amount. cost-sharing amount.
If you request a formulary If you request a formulary
exception for a drug and exception for a drug and
(Regional PPO) approves (Regional PPO) approves
the exception, you will pay the exception, you will pay
Tier 3 Non-Preferred Non-Preferred Brand &
Brand & Certain Generic Certain Generic Drugs
Drugs cost-sharing for that cost-sharing for that drug.
drug.

$0 deductible. $0 deductible.
Some covered drugs don’t Some covered drugs don’t
count toward your out-of- count toward your out-of-
pocket drug costs. pocket drug costs.

Initial Coverage Initial Coverage
You pay the following until You pay the following until
total yearly drug costs reach total yearly drug costs reach
$2,830: $2,830:

Retail Pharmacy Retail Pharmacy
Tier 1 Preferred Preferred Generic
Generic Drugs Drugs
 $7 copay for a one-month  $7 copay for a one-month
(30-day) supply of drugs (30-day) supply of drugs
in this tier in this tier
 $21 copay for a three-  $21 copay for a three-
month (90-day) supply of month (90-day) supply of
drugs in this tier drugs in this tier


PPO)
Tier 2 Preferred Brand Preferred Brand &
& Certain Generic Certain Generic Drugs
Drugs  $43 copay for a one-
 $43 copay for a one- month (30-day) supply of
month (30-day) supply of drugs in this tier
drugs in this tier
 $129 copay for a three-
 $129 copay for a three- month (90-day) supply of
drugs in this tier
Tier 3 Non-Preferred Non-Preferred Brand &
Brand & Certain Certain Generic Drugs
Generic Drugs  $85 copay for a one-
 $85 copay for a one- month (30-day) supply of
drugs in this tier  $255 copay for a three-
 $255 copay for a three- month (90-day) supply of
drugs in this tier
Non-Specialty
Tier 4 Non-Specialty Injectable Drugs
Injectable Drugs  33% coinsurance for a
 33% coinsurance for a one-month (30-day)
one-month (30-day) supply of drugs in this
supply of drugs in this tier
tier  33% coinsurance for a
 33% coinsurance for a three-month (90-day)
three-month (90-day) supply of drugs in this
tier
Specialty Drugs
Tier 5 Specialty Drugs  33% coinsurance for a
 33% coinsurance for a one-month (30-day)
one-month (30-day) supply of drugs in this
tier
Long-Term Care
Long-Term Care Pharmacy
Pharmacy
Preferred Generic
Tier 1 Preferred Drugs
Generic Drugs  $7 copay for a one-month
 $7 copay for a one-month (34-day) supply of drugs


PPO)
(34-day) supply of drugs in this tier
in this tier
Tier 2 Preferred Brand
& Certain Generic Preferred Brand &
Drugs Certain Generic Drugs
 $43 copay for a one-  $43 copay for a one-
Tier 3 Non-Preferred
Brand & Certain Non-Preferred Brand &
Generic Drugs Certain Generic Drugs
Tier 4 Non-Specialty Non-Specialty
Injectable Drugs Injectable Drugs
 33% coinsurance for a  33% coinsurance for a
one-month (34-day) one-month (34-day)
supply of drugs in this supply of drugs in this
tier tier
Tier 5 Specialty Drugs Specialty Drugs
tier tier

Mail Order Mail Order
Generic Drugs Drugs
 $10.50 copay for a three-  $10.50 copay for a three-
drugs in this tier from a drugs in this tier from a
preferred mail-order preferred mail-order
pharmacy. pharmacy.
non-preferred mail-order non-preferred mail-order
pharmacy. pharmacy.


PPO)
 $107.50 copay for a  $107.50 copay for a
three-month (90-day) three-month (90-day)
tier from a preferred mail- tier from a preferred mail-
order pharmacy. order pharmacy.
pharmacy. pharmacy.
 $212.50 copay for a  $212.50 copay for a
pharmacy. pharmacy.
tier from a non-preferred tier from a non-preferred
mail-order pharmacy. mail-order pharmacy.
Tier 5 Specialty Drugs Specialty Drugs


PPO)
mail-order pharmacy. mail-order pharmacy.
Coverage Gap Coverage Gap
The plan covers many The plan covers many
generics (65%-99% of generics (65%-99% of
formulary generic drugs) formulary generic drugs)
through the coverage gap. AND
You pay the following: few brands (less than 10%
of formulary brand drugs)
through the coverage gap.
You pay the following:

Retail Pharmacy Retail Pharmacy
Generic Drugs Drugs
(30-day) supply of all (30-day) supply of all
drugs covered in this tier drugs covered in this tier
all drugs covered in this all drugs covered in this
tier tier

Long-Term-Care Long-Term-Care
Pharmacy Pharmacy
Generic Drugs Drugs
(34-day) supply of all (34-day) supply of all
drugs covered in this tier drugs covered in this tier


PPO)
Mail Order Mail Order
Generic Drugs Drugs
 $10.50 copay for a three-  $10.50 copay for a three-
order pharmacy order pharmacy
mail-order pharmacy mail-order pharmacy
For all other covered drugs, For all other covered drugs,
after your total yearly drug after your total yearly drug
costs reach $2,830, you pay costs reach $2,830, you pay
100%, until your yearly 100%, until your yearly
out-of-pocket drug costs out-of-pocket drug costs
reach $4,550. reach $4,550.

Catastrophic Catastrophic
Coverage Coverage
After your yearly out-of- After your yearly out-of-
pocket drug costs reach pocket drug costs reach
$4,550, you pay the greater $4,550, you pay the greater
of: of:
 A $2.50 copay for generic  A $2.50 copay for generic
(including brand drugs (including brand drugs
treated as generic) and a treated as generic) and a
$6.30 copay for all other $6.30 copay for all other
drugs, or drugs, or
 5% coinsurance.  5% coinsurance.

Plan drugs may be covered Plan drugs may be covered
in special circumstances, in special circumstances,
for instance, illness while for instance, illness while
traveling outside of the traveling outside of the
plan’s service area where plan’s service area where
there is no network there is no network
pharmacy. You may have pharmacy. You may have
to pay more than your to pay more than your


PPO)
normal cost-sharing normal cost-sharing
amount if you get your amount if you get your
drugs at an out-of-network drugs at an out-of-network
pharmacy. In addition, you pharmacy. In addition, you
will likely have to pay the will likely have to pay the
pharmacy’s full charge for pharmacy’s full charge for
the drug and submit the drug and submit
documentation to receive documentation to receive
reimbursement from reimbursement from
(Regional PPO). (Regional PPO).

Initial Coverage Initial Coverage
You will be reimbursed up You will be reimbursed up
to the full cost of the drug, to the full cost of the drug,
minus the following for minus the following for
drugs purchased out-of- drugs purchased out-of-
network until total yearly network until total yearly
drug costs reach $2,830: drug costs reach $2,830:
Generic Drugs Drugs
(30-day) supply of drugs (30-day) supply of drugs
in this tier in this tier
tier tier


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