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SUPPLEMENT-TYPE MEDICAL PLANS | Summary of Benefits | Continued
Supplement-Type Standard Plan
Supplement-Type Enhanced Plan
10% coinsurance, deductible applies.
Member pays $0.
*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. ITDR Benefit Questions: (877) 325-7265, select Option 2
If your Medical Plan has a deductible, it must be met before copayments or coinsurance will apply. See page 42 for details regarding Prescription Drug Plan deductible, copays and coinsurance.
Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide | 33
EYE HEALTH*