Ppo Br Md Pref Sta Pr Va

7/31/2019 Ppo Br Md Pref Sta Pr Va

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About Medicare

Signed into law in 1965, OriginalMedicare is the national healthinsurance program that the federal

government extends to people:

Who are 65 or older.

Who are under 65 with disabilities.

Of any age with end-stage renaldisease (ESRD) or permanent kidneyfailure treated with dialysis or akidney transplant.

Things to keep in mind Our Medicare Advantage PPO plans

(Part C plans) take the place ofMedicare Part A and Part B and mayoffer more benefits than OriginalMedicare.

Medicare pays Medicare Advantageplans monthly to provide you withhospital and medical coverage.

Original Medicare will pay forhospice care and some costs forclinical trials.

To enroll in Medicare Advantage,you must be enrolled in both Parts

A and B. You, Medicaid or anotherthird party must continue to payyour Part B premium.

Y0071_11_10158_R_012 CMS Approved 09/08/2010 14910WPMENMUB_012

H4909 001 004 VA

Your advantage

If you choose one of our Medicare

Advantage plans with Part D

coverage, one ID card is all you

need for your hospital, medical

and pharmacy benefits.


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Part C, or Medicare Advantage, is what we offer as an alternative to OriginalMedicare and covers Parts A and B and other services. Most of our Medicare

Advantage PPO plans include Part D, prescription drug coverage.

To learn more about Parts A, B, C and D, see theMedicare & You 2011 handbookatwww.medicare.gov.

PART C takes the place of Medicare Part A and Part B, and may include morebenefits than Original Medicare A and B. These are called Medicare Advantage plansand are only available from private insurers contracted with Medicare. Part C mayhave deductibles, copays and coinsurance.

PART D is only offered through private insurers contracted with Medicare. OriginalMedicare does not offer prescription drug coverage (Part D). Our MAPD plans thatinclude Part D have copays or coinsurance.

Original Medicare:

PART A takes care of services such as inpatient care in a hospital, skilled nursingfacility or hospice and home health care if you meet certain conditions. Part A hasdeductibles, copays and coinsurance. Part A is funded by the taxes that you or yourspouse paid when you were working.

PART B helps pay doctors services, lab services, clinical trials, home health care,outpatient hospital care, durable medical equipment and some services not coveredby Part A. Part B has deductibles, copays and coinsurance. Most of us pay thestandard monthly Part B premium. If you receive a monthly benefit payment from theSocial Security Administration, the Railroad Retirement Board, or the Civil Service,you must have your Part B premiums deducted from your monthly benefit payment. Ifyou do not receive benefit payments, Medicare will bill you directly for your premiums.You may choose to pay by check or money order, credit card, or have it automaticallydeducted from your bank account. Payments cannot be made over the phone.

Original Medicare covers Part A (hospital) and Part B (medical) benefits only.


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What you get with an AnthemBlue Cross and Blue Shield PPO

We designed our Medicare Advantageplans to help you find the right planat the right price for your own specificneeds. They offer you protection fromunexpected medical expenses, withpremiums as low as $0. Plus, you alsohave the freedom to go to the provider

of your choice, without referral, insideor outside our plans network. Note that

with the exception of emergencies orurgent care, it may cost more to get carefrom out-of-network providers.

We also include many benefits notoffered by Medicare Parts A and B.These include services designed tosupport a healthy lifestyle, and more

ways to cover your medical and health-related expenses.

With just the one ID card you receivefrom us, you get your Medicare-coveredhospital and medical benefits, and more:

Monthly premiums as low as $0

Many benefits with set copays

Preventive care with $0 copays whenyou use in-network providers1

Part D prescription drug coverage for most plans

Dental, vision, hearing exams for select plans

Emergency and urgent care inside andoutside the U.S.

Programs to help manage your care2

Gym membership at no cost to you2

Online resources and discounts2

Coverage for some costs forclinical trials

Set copays means no surprises

With an Anthem Blue Cross and

Blue Shield PPO, you have set

copays for many services, which

means you will know ahead of

time what you have to pay for.

In addition, our plans come with

out-of-pocket maximums, which

may limit your financial risk due to

unexpected medical expenses.

You must continue to pay your Part B premium. For more information on benefitsavailable to you, be sure to check the Summary of Benefits Section in this booklet.

1 Preventive care includes items such as annual physical exams, mammograms, Pap smearsand pelvic exams, prostate screenings, immunizations, colorectal screenings and bone massmeasurements. This is not all-inclusive; please refer to the Summary of Benefits section formore details.

2 See these sections later in this booklet for more details.


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You are free to chooseother options

If you want more than the standardbenefits of our Anthem Blue Crossand Blue Shield (Local PPO) plans,you have the freedom to choose fromour enhanced benefits packages. For alittle bit more in monthly premiumsthat cost as low as $9, you can getenhanced dental, vision, chiropracticand acupuncture coverage. All theseenhanced packages are optional andcome at various levels of coverage andcost, to fit your budget and needs.


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Free to choose your providers

Your costs are lower withnetwork providers

Do you have a doctor you like? Great!Is he or she in a Medicare AdvantagePPO provider network? Thats evenbetter. That means you may pay less foryour medical costs. Network providerscontract with us to accept agreed-uponMedicare rates as payment in full. Theycant charge you more. Please check tosee if your doctor is part of your plansnetwork. Otherwise, feel free to shop,compare and choose a doctor inside oroutside your network. In many cases,

except for emergencies, you will paymore for out-of-network providers, sowhy not use network providers to helpkeep your medical costs down?

You dont need referrals

As a PPO member, you dont need adoctors OK to go to any provider ofyour choice inside or outside our plansnetwork. Thats the flexibility you get

with any of our PPO plans.

Feel free to travel anywherewe cover

Through the Medicare Advantage PPOvisitor/travel program, you will be ableto receive services using your in-networkbenefits when you visit certain areas

within 29 states and Puerto Rico. Youmay be able to access your benefits

while out of our service area for sixmonths if the place youre visiting is onthe coverage list. If you do get care froma network provider where the travelprogram is in place, your cost share

while out of the service area will be

the same as your in-network cost sharewhile in the service area. Call us at1-800-916-2583 (TTY/TDD line at1-800-241-6894) 8 a.m. 8 p.m.,7 days a week, for a list of the states

where the travel program applies.


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Thats of course, if you pick a PPOplan with prescription drug coverage.Original Medicare does not cover mostprescription drugs. We do with mostof our PPO plans. We think hospital,

medical care and prescription coverageshould go hand in hand. As part ofyour Part D plan, we will cover genericdrugs that are included on tier 1 ofyour covered drug list (formulary)through the coverage gap. During thisphase, all you will pay for is the tier 1Initial Coverage Limit copay for thegeneric drugs included on your tier 1covered list.

And, you have one customer servicephone number to call with any medicalor prescription drug questions you mayhave.

Eligible beneficiaries must use networkpharmacies to access their prescriptiondrug benefit except under non-routinecircumstances, and quantity limitationsand restrictions may apply.

Convenient ordering options

When you need your medicine rightaway for a limited period, you canuse retail plan pharmacies or drugstores

to fill your order for up to a 90-daysupply only some pharmacies arecontracted to provide 90-day retailsupply.

If you need to take your drugs on anongoing basis, you can also feel free touse our network mail-order pharmacy.

You can order your first prescriptionand refills with ease and convenience

through the mail or by phone.

Your advantage

As a Medicare Advantage PPOplan member, you have accessto pharmacy networks with more

than 65,000 retail pharmaciesacross the country.

Your drug coverage options


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If you do not have access to one of ournetwork pharmacies, you can fill yourprescription drugs under the followingcircumstances:

You are traveling within the United

States and its territories and becomeill, or lose or run out of yourprescription drugs.

The prescription is for a medicalemergency or urgent care.

You are unable to obtain a covereddrug in a timely manner withinour service area because a networkpharmacy that provides 24-hour

service is not available within a25-mile driving distance.

You are filling a prescription for acovered drug that is not regularlystocked at an accessible networkretail or pharmacy. (For example,an orphan drug or other specialtypharmaceutical.)

In these situations, please call Customer

Service to see if there is a networkpharmacy nearby.

New: 2011 Part D discount

If you have Medicare Part D,prescription drug coverage, and youreach the Medicare coverage gap, you

will get a 50% discount on your brand-name prescribed drugs at the timeyou buy them. The discount does notapply if you are getting Medicare ExtraHelp. The coverage gap is the period

when you have to pay all out-of-pocketcosts (up to a limit) for your coveredprescribed drugs. This happens whenyou and your Medicare plan havereached the Initial Coverage Limit set

by Medicare. Extra Help is the financialaid that Medicare offers to low- andlimited-income Medicare beneficiariesto pay for covered prescribed drugs.


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When you need Extra Help

You may be able to get MedicaresExtra Help to pay for prescription drugpremiums and copays. Through thislimited-income program, Medicare couldpay up to 100% of your prescribed drugcosts. You will not be subject to thecoverage gap or a late enrollment penalty,if you miss the seven-month eligibilityperiod (three months before you turn 65,the month when you turn 65, and threemonths after you turn 65).

If you qualify for Medicares Extra Helpand are enrolled in a Part D plan, you

will get:

Help paying for your drug plansmonthly premium, yearly deductible,coinsurance and copays for prescriptiondrugs that are on your plans list ofcovered drugs.

No coverage gap.

No late enrollment penalty, if you missthe seven-month eligibility period (threemonths before you turn 65, the month

when you turn 65, and three monthsafter you turn 65).

You will qualify for Extra Help if you haveone of these:

Both Medicare and Medicaid

Help from Medicaid paying yourMedicare Part B

Both Medicare and SupplementalSecurity Income (SSI)

Call any of these numbers to find out ifyou qualify for or need more informationabout the Extra Help program:

1-800-MEDICARE1-800-633-4227 any time, day ornight. TTY or TDD users may call

1-877-486-2048. The Social Security Office at

1-800-772-1213 between 7 a.m.and 7 p.m. Monday through Friday.TTY or TDD users should call1-800-325-0778.

Your State Medical Assistance(Medicaid) Office


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Programs to help manage your care

Along with medical and prescriptioncoverage through your PPO plan, youget extra services from us. We help youlower your medical bills and give youaccess to resources to help you improveyour quality of life.

ConditionCare: Knowing the mostabout a condition can help youlead a more active life

With ConditionCare, you can take partin our preventive care services. Or, ifyou have or develop complex healthissues you can turn to Anthem BlueCross and Blue Shield resources forsupport.

Through our ConditionCare program,you and your doctor can work witha team of nurses to help you followyour plan of care and reach your

wellness goals. Trained nurses can helpyou learn to keep symptoms of yourchronic condition under control. Nursecare managers offer integrated caremanagement services, including lifestylecoaching, to help you deal with thechallenges of having a single or multiplehealth conditions.

MyHealth Advantage:Staying a step ahead can leadto better outcomes

The sooner you know of any healthrisks you may have, the sooner youcan address them. Through MyHealth

Advantage, we are able to review yourhealth status on a regular basis. If wedetect risk issues from the drugs youretaking, we alert you and your doctor.

We keep track of your routine testsand checkups and send you a reminderto keep you up-to-date. If you havequestions about the information youget, you can call our health coachestoll-free. We also offer tips that may

help save you money on prescriptiondrugs and other health care supplies.

24/7 NurseLine: RNs can help youby phone 24 hours day

What if you get sick or injured whenyour doctors office is closed? Anytimeday or night, you can call the 24/7NurseLine toll-free. Registered nurses(RNs) will help assess your symptoms

and talk with you about your optionsfor care. You can program the 24/7NurseLine number into all your phones.That way, youre just one touch awayfrom the help you need. You also haveaccess to hundreds of taped healthtopics in English and Spanish. Just callthe nurse line and follow the prompts toget to the 24/7 NurseLine audio library.


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Gym membership and onlineresources and discounts

Staying active and staying fit leads toa healthier you. Thats why we madegym membership to SilverSneakersone of your benefits. Just take your

Anthem Medicare Preferred (PPO) ID

card to a participating gym and sign upat no extra cost. To find a participatinglocation, visitwww.silversneakers.com.

You can get fit and stay healthy with theSilverSneakers Fitness Program. At thegym, you can:

Consult with one of the trainers to getyou started with your own program.

Use the exercise equipment.

Take part in conditioning andstrengthening classes.

Attend health education seminars.

Get online support to help youmanage your weight, quit smokingor reduce stress.

Going to the gym means getting fit,having fun with others and makingnew friends.

1 Centers for Disease Control and Prevention,Managed-Medicare Health Club Benefit andReduced Health Care Costs Among Older Adults, Vol. 5, No. 1, January 2008(Accessed June 2010) http://www.cdc.gov/pcd/issues/2008/jan/07_0148.htm

Did you know?

A Centers for Disease Controland Prevention study,published in January 2008,proved the merits of theSilverSneakers programas a Medicare benefit. Thestudy found gym membershiplowered inpatient admissionsand total health care costsamong older adults over atwo-year period.1


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2 Vendors and offers are subject to change without prior notice. Anthem Blue Cross andBlue Shield does not endorse and is not responsible for the products, services or informationprovided by the SpecialOffers vendors. Arrangements and discounts were negotiated betweeneach vendor and Anthem Blue Cross and Blue Shield for the benefit of our members.

MyHealth@Anthem helps youtake control of your health

Youre getting ready for bed. It dawns onyou that you need to know somethingbefore you see your doctor the next day.No problem. You go to the AnthemBlue Cross and Blue Shield website andlog on to MyHealth@Anthem. You canaccess the site 24 hours a day to findhealth tips and tools that can help youtake control of your health. The sitealso has health management programsand health news to help you make moreinformed health care decisions. All youll

need to do is sign up online once yourea member.

SpecialOffers@Anthem:Savings and discounts just for you

Of course we want to help you savemoney! Wherever we can. Whenever wecan. As a member, you can cut costs bygoing to network providers and usinggeneric drugs on our preferred drug list.Depending on the plan you choose,you may get discounts for vision,hearing and dental services. ThroughSpecialOffers@Anthem, you can accessdiscounts on various alternative healthproducts and services. Check out our

website for a complete list of discounted

products and services.2


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Things to know before you enroll

1Learn more about us atwww.anthem.com.

Emergency care anywhere

If you think your health is in seriousdanger, call 911 or go to the nearestemergency room (ER) right away.

We will cover care for a true emergency

inside and outside the United States.We encourage our members not to usethe emergency room for routine care.Its best for you to go to your regulardoctor for routine care because yourdoctor knows you and your medicalhistory, and keeps your medical records.

Your right to appeal

When youre not happy with yourhealth care service, were not happy.We hope that never happens. But ifever you have a concern or cannotagree with a claim decision or a denial,feel free to pursue your options. We

will do our best to give you all theinformation you need. We will listento your concerns. Thats why we haveappeals and grievance procedures. We

review a grievance, such as a quality ofcare complaint, within 30 days after

we receive the complaint. We addressappeals issues, such as payment forservices, within 60 days after we receivethe appeal. If the appeal is for a denied

service, we must decide no later than 30days after we receive the appeal. If yourhealth is at risk, we must respond to theappeal within 72 hours. Under somecircumstances, you have the right to filean expedited grievance (rush grievance).

In such a case, we must respond within24 hours after we receive the grievance.

And were happy to do so.

Count on the experience of aname you can trust

Heres a little more information

that can help put your mind at ease.

Consider that the services youll get

come from a company that you may

already know one that generations

have relied on with confidence

Anthem Blue Cross and Blue Shield.

You, your family and friends may have

received our services in the past. After

all, we started offering health care

coverage more than 75 years ago.1

Today, together with our affiliates, weserve more than 33 million members

across the United States.1 If that many

trust us with their care, we must be

doing something right!


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Make sure youre eligible

If you have Medicare Part A (hospital)and Part B (medical), and you sign upduring an enrollment period, youll beable to join a Medicare Advantage plan.To qualify, you must live in our servicearea. Per Medicare rules, you cant joina Medicare Advantage plan if you haveend-stage renal disease.

When you can join

Medicare limits when and how oftenyou can change the way you get benefitsthrough a Medicare Advantage plan.Please check theMedicare & You 2011handbook on the Medicare website(www.Medicare.gov) for enrollmentinformation on when you can join,switch or drop a Medicare Advantageplan. Here is a brief timeline:

Initial enrollment period 7 months surrounding your Medicareeligibility: This is the 3 months before youturn 65, the month when you turn 65,

and the 3 months after you turn 65.

Annual election period November 15 to December 31. Theperiod you can enroll in or change yourMedicare Advantage plan. You mayalso switch to Original Medicare. Newcoverage will begin January 1, 2011.

Annual disenrollment period January 1 to February 14. You maydisenroll from your Medicare Advantageplan. During this time, you will be

enrolled in Original Medicare and willhave the option of choosing a stand-aloneprescription drug plan.

Special enrollment period Based on each persons situation

Anytime Only if you qualify for Extra Help or ifyou have both Medicaid and Medicare


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The enrollment process

When you are ready and have madeup your mind, you dont need to geta physical exam to enroll. We will notreject your application because of apre-existing medical condition, except

end-stage renal disease.You will need information fromyour Medicare card to fill outyour enrollment form. Your salesrepresentative or agent can assist youand collect a copy for your enrollment.Or you can tear out a copy and submitthe top copy of each page to the addresslisted on the first page of the enrollment

application. You can also enroll onlineatwww.anthem.com/medicare.

After you submit yourenrollment application:

1. We will send you a letter to confirmthat we have your application. Theletter will include your proposedeffective date. You may use the letteras proof of membership until yourmember ID card arrives.

2. We will send your application toCMS for approval.

3. When approved by CMS, you willget a welcome letter that confirmsyour effective date with us. You will

get your member ID card and othernew member materials.

Paying your monthly premium

You need to continue to pay yourMedicare Part B premium.

If your plan has a premium, you canpay your premium in several ways.

Choose your plan payment optionon your enrollment application:

Option 1: By check. If you choose topay your premium directly to us, you

will get a bill each month.

Option 2: By automatic withdrawal.

Option 3: Taken out of your monthlySocial Security check.


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For more information on Anthem Blue Cross and Blue Shields plan ratings information,go towww.medicare.gov.

Anthem Blue Cross and Blue Shield renews its contract with Medicare (the federal government) eachyear on January 1. Premiums and benefits may change at that time, but not during the year unlessthe change is to your advantage. In addition, the plan may reduce its service area and no longer offer

services in the area where the beneficiary resides. If we do not renew our contract, well tell you atleast 90 days in advance. You may then switch to a standard Medigap plan (A, B, C or F) that wontdeny coverage because of a pre-existing condition. It will normally go into effect the day after yourMedicare Advantage membership ends.

A health plan with a Medicare contract.

The person who is discussing plan options with you is either employed by or contracted withAnthem Blue Cross and Blue Shield. The person may be compensated based on your enrollmentin a plan.

The benefit information provided herein is a brief summary, not a comprehensive descriptionof benefits. For more information contact the plan.

This plan is a PPO with a Medicare contract.

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia,and its service area is all of Virginia except for the city of Fairfax, the town of Vienna and the areaeast of State Route 123. Anthem Blue Cross and Blue Shield is an independent licensee of the BlueCross and Blue Shield Association. ANTHEM is a registered trademark of Anthem InsuranceCompanies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of theBlue Cross and Blue Shield Association.

SilverSneakers is a registered mark of Healthways, Inc. Healthways, Inc. is an independentcompany.

Were here to help

Call your local agent or one of our health benefits advisors at1-800-916-2583 (TTY/TDD line at 1-800-241-6894),8 a.m. 8 p.m., 7 days a week.Or, visit us online atwww.anthem.com/medicare.

You can call Medicare for basic questions about how Medicare works at1-800-MEDICARE (1-800-633-4227) or the TTY/TDD line1-877-486-2048, 24 hours a day, 7 days a week.


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Ppo Br Md Pref Sta Pr Va