HIPAA Substitute Notice ®Registered marks Blue Cross and Blue Shield Association ©2013 copyright of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield is a Health plan with a Medicare contract. A stand-alone prescription drug plan with a Medicare contract. The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed. You are eligible to enroll if you are entitled to Medicare Part A and enrolled in Medicare Part B and you live in the service area. You must continue to pay your Medicare Part B premium. With some exceptions you can only enroll during certain times of the year. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and or co-payments/co-insurance may change on January 1 of each year. This information is available for free in other languages. To obtain an aggregate number of grievances, appeals and exceptions filed or for full information on benefits, please call Customer Service. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits. If you have special needs, our Plan documents may be available in other formats. Please call Customer Service for details. Y0071_13_16834_R CMS Approved 04/05/2013 Last Updated 03/29/2013 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri (excluding 30 counties in the Kansas City area), Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use.