Page 37 - Benefits-Guide-2020

Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
*Eye health refers to glaucoma screenings for high risk members, diabetic retinopathy screening, macular degeneration tests and treatment, and eye protheses (replacement covered once every five years).
For a complete list of services, refer to the Evidence of Coverage (EOC) for each plan, which is available at www.anthem.com. An additional resource is the “Medicare & You” handbook, which Medicare will mail to you each year. You can also access it online anytime at https://www.medicare.gov/medicare-and-you/ medicare-and-you.html.
Anthem Blue Cross and Blue Shield is an LPPO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal. Anthem Insurance Companies, Inc. (AICI) is the legal entity that has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer the LPPO plan noted above or herein. AICI is the risk-bearing entity licensed under applicable state law to offer the LPPO plan(s) noted. AICI has retained the services of its related companies and the authorized agents/brokers/producers to provide administrative services and/or to make the LPPO plan(s) available in this region. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
This information is not a complete description of benefits. Call 1-844-889-6357 for more information.
Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our member services number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Unless otherwise noted: For the Medicare Advantage Standard Plan, members must meet their calendar-year deductible for all Part A and Part B covered services before their copayment or coinsurance will apply. For the Supplement-Type Standard Plan, members have no deductible to meet for Part A services, but for Part B services, members must meet their calendar-year deductible before their coinsurance will apply.
MEDICAL PLANS | Summary of Benefits | Continued
Medicare Advantage Standard Plan
Medicare Advantage Enhanced Plan
10% coinsurance.
Member pays $0.
$5 copay for visits to a primary care physician for exams to diagnose and treat diseases
of the eye.
$40 copay for visits to a specialist for exams to diagnose and treat diseases of the eye.
$0 copay for glaucoma and diabetic retinopathy screenings. Deductible does not apply.
10% coinsurance for glasses/contacts following cataract surgery.
$10 copay for visits to a primary care physician for exams to diagnose and treat diseases
of the eye.
$25 copay for visits to a specialist for exams to diagnose and treat diseases of the eye.
$0 copay for glaucoma and diabetic retinopathy screenings.
10% coinsurance for glasses/contacts following cataract surgery.
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EYE HEALTH*