Summary of benefits medicare insurance program

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Summary of Benefits

for Anthem Senior Advantage Value (HMO)

Available in Belmont, Columbiana, Cuyahoga, Delaware, Fairfield, Franklin, Hamilton, Harrison, Jefferson, Licking, Madison, Mahoning, Montgomery, Muskingum, Summit, Trumbull, and Union Counties in Ohio

This plan is an HMO with a Medicare contract. Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. 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.

Y0071_12_12913_T_034 CMS Approved 09/15/2011

23461MUSENMUB_034 H3655 031 OH HMO

Section I:

Introduction to the Summary of Benefits

Thank you for your interest in Anthem Senior Advantage Value (HMO). Our plan is offered by Anthem Blue Cross and Blue Shield, a Medicare Advantage Health Maintenance Organization (HMO). This Summary of Benefits tells you some features of our plan. 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 Anthem Senior Advantage Value (HMO) and ask for the "Evidence of Coverage".

You Have Choices in Your Health Care

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Anthem Senior Advantage Value (HMO). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program.

You may join or leave a plan only at certain times. Please call Anthem Senior Advantage Value (HMO) at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

How Can I Compare My Options?

You can compare Anthem Senior Advantage Value (HMO) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

Belmont, Columbiana, Cuyahoga, Delaware, Fairfield, Franklin, Hamilton, Harrison, Jefferson, Licking, Madison, Mahoning, Montgomery, Muskingum, Summit, Trumbull, Union counties, OH. You must live in one of these areas to join the plan.

Who Is Eligible to Join Anthem Senior Advantage Value (HMO)?

You can join Anthem Senior Advantage Value (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease are generally not eligible to enroll in Anthem Senior Advantage Value (HMO) unless they are members of our organization and have been since their dialysis began.

Can I Choose My Doctors?

Anthem Senior Advantage Value (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at medicare. Our customer service number is listed at the end of this introduction.

Where Is Anthem Senior Advantage Value (HMO) Available?

The service area for this plan includes the following counties:

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What Happens If I Go to a Doctor Who's Not in Your Network?

If you choose to go to a doctor outside of our network, you must pay for these services yourself except in limited situations (for example, emergency care). Neither the plan nor the Original Medicare Plan will pay for these services

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

Where Can I Get My Prescriptions If I Join this plan?

Anthem Senior Advantage Value (HMO) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at medicare. Our customer service number is listed at the end of this introduction.

Does My Plan Cover Medicare Part B or Part D Drugs?

Anthem Senior Advantage Value (HMO) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs.

How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra Help With Other Medicare Costs?

You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call:

* 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week and see 'Programs for People with Limited Income and Resources' in the publication Medicare & You.

* The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 or

* Your State Medicaid Office.

What Is a Prescription Drug Formulary?

Anthem Senior Advantage Value (HMO) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any 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 Web site at medicare.

What Are My Protections in this plan?

All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

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As a member of Anthem Senior Advantage Value (HMO), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. 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 or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

As a member of Anthem Senior Advantage Value (HMO), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement

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Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

What Is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Anthem Senior Advantage Value (HMO) for more details.

What Types of Drugs May Be Covered Under Medicare Part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Anthem Senior Advantage Value (HMO) for more details.

Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare. Erythropoietin (Epoetin Alfa or Epogen?): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. Injectable Drugs: Most injectable drugs administered incident to a physician's service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the 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 Medicare-certified facility. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.

Inhalation and Infusion Drugs administered through DME.

Where Can I Find Information On Plan Ratings?

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing

illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select "Health and Drug Plans" then "Compare Drug and Health Plans" to compare the Plan Ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the Plan Ratings for this plan. Our customer service number is listed below.

Please call Anthem Blue Cross and Blue Shield for more information about Anthem Senior Advantage Value (HMO).

Visit us at medicare or, call us:

Customer Service Hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. Eastern

Current members should call toll-free for questions related to the Medicare Advantage program or the Medicare Part D Prescription Drug program. 1-800-467-1199 (TTY/TDD 711)

Prospective members should call toll-free for questions related to the Medicare Advantage program or the Medicare Part D Prescription Drug program. 1-866-803-5169 (TTY/TDD 711)

Current members should call locally for questions related to the Medicare Advantage program or the Medicare Part D Prescription Drug program. 1-800-467-1199 (TTY/TDD 711)

Prospective members should call locally for questions related to the Medicare Advantage program or the Medicare Part D Prescription Drug program. 1-866-803-5169 (TTY/TDD 711)

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Or, visit on the Web.

This document may be available in other formats such as Braille, large print or other alternate formats.

This document may be available in a non-English language. For additional information, call customer service at the phone number listed above.

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If you have any questions about this plan's benefits or costs, please contact Anthem Blue Cross and Blue Shield for details

Section II:

Summary of Benefits

Benefit

Original Medicare

Anthem Senior Advantage Value (HMO)

IMPORTANT INFORMATION

1 Premium and In 2011 the monthly Part B Premium was General

Other Important $96.40 and may change for 2012 and the $0 monthly plan premium in addition to your

Information

annual Part B deductible amount was $162 monthly Medicare Part B premium.

and may change for 2012.

Most people will pay the standard monthly

Part B premium in addition to their MA plan

If a doctor or supplier does not accept

premium. However, some people will pay

assignment, their costs are often higher, which higher Part B and Part D premiums because

means you pay more.

of their yearly income (over $85,000 for

singles, $170,000 for married couples). For

Most people will pay the standard monthly more information about Part B and Part D

Part B premium. However, some people will premiums based on income, call Medicare at

pay a higher premium because of their yearly 1-800-MEDICARE (1-800-633-4227). TTY

income (over $85,000 for singles, $170,000 users should call 1-877-486-2048. You may

for married couples). For more information also call Social Security at 1-800-772-1213.

about Part B premiums based on income, call TTY users should call 1-800-325-0778.

Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call In-Network 1-877-486-2048. You may also call Social $3,400 out-of-pocket limit for Security at 1-800-772-1213. TTY users should Medicare-covered services.

call 1-800-325-0778.

2 Doctor and

You may go to any doctor, specialist or

Hospital Choice hospital that accepts Medicare.

(For more

information, see

Emergency Care -

#15 and Urgently

Needed Care -

#16.)

In-Network You must go to network doctors, specialists, and hospitals.

No referral required for network doctors, specialists, and hospitals.

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23461MUSENMUB_034

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