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Plans and Benefits

PW_039716

Anthem Senior Advantage offers 4 four plans: Choice, Select, Custom, and Custom Plus. 
Anthem Senior Advantage Benefit Medicare (2004 Benefit) Choice Select Custom Custom Plus Notes
Part A: Inpatient Hospital 
Initial Deductible: 1-60 
$876 
$0 
$0 
$0 
$0 
 
Hospital Coinsurance: 61-90 
$219/day 
$0 
$0 
$0 
$0 
 
Hospital Coinsurance: 91-150 
$438/day 
$0 
$0 
$0 
$0 
 
Skilled Nursing Facility: 21-100 
$109.50/day 
$0 
$0 
$0 
$0 
 
Part A: Inpatient Mental Health Care (190 days lifetime) 
Initial Deductible: 1-60 
$876 
$0 
$0 
$0 
$0 
 
Hospital Coinsurance: 61-90 
$219/day 
$0 
$0 
$0 
$0 
 
Hospital Coinsurance: 91-150 
$438/day 
$0 
$0 
$0 
$0 
 
Part B: Outpatient 
Annual Deductible 
$100 
$0 
$0 
$0 
$0 
 
Physician Office Visits 
20% 
$5 
$5 
$5 
$5 
 
Specialist Office Visits 
20% 
$15 
$15 
$15 
$15 
 
Chiropractic Services (Medicare covered) 
20% 
$15 
$15 
$15 
$15 
 
Podiatry Services (Medicare covered) 
20% 
$15 
$15 
$15 
$15 
 
Mental Health Therapy Visit 
50% 
$15 
$15 
$15 
$15 
 
Mental Health Psychiatrist Visit 
50% 
$15 
$15 
$15 
$15 
 
Substance Abuse 
20% 
$15 
$15 
$15 
$15 
 
Outpatient Surgery 
20% 
$0 
$0 
$0 
$0 
 
Ambulance Services 
20% 
$0 
$0 
$0 
$0 
 
Emergency Services (Medicare covered) 
20% 
$50 
$50 
$50 
$50 
Worldwide 
Urgent Care 
20% 
$50 
$50 
$50 
$50 
Not outside U.S. 
Occupational, Speech and Physical Therapies 
20% 
$5 
$5 
$5 
$5 
 
Durable Medical Equipment (DME) 
20% 
$0 
$0 
$0 
$0 
 
Prosthetic Devices 
20% 
20% 
20% 
20% 
20% 
 
Diabetes Self-monitoring 
20% 
20% 
20% 
20% 
20% 
 
X-ray, and other Diagnostic Tests 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Approved Lab Services 
0% 
$0 
$0 
$0 
$0 
Office copay may apply 
Radiation Therapy 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Chemotherapy 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Pulmonary Rehabilitation 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Cardiac Rehabilitation 
20% 
$0 
$0 
$0 
$0 
 
Renal Dialysis 
20% 
$0 
$0 
$0 
$0 
 
Preventive Services 
Bone Mass Measurement 
20% 
$15 
$15 
$15 
$15 
 
Colorectal Screening 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Immunizations (Flu, Pneumonia., Hepatitis B) 
$0 
$0 
$0 
$0 
$0 
Office copay for Hepatitis B 
Mammograms 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Pap Smears (annual) and Pelvic Exams 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
OB/Gyn (all visits) 
20% 
$5 
$5 
$5 
$5 
 
Prostate Cancer Screening 
20% 
$0 
$0 
$0 
$0 
Office copay may apply 
Additional Benefits (not covered by Medicare) 
Routine Preventive Dental Care 
Not covered 
Not covered 
Not covered 
Not covered 
Not covered 
 
Routine Hearing Screening  
Not covered 
$5 
$5 
$5 
$5/ 
1 exam per year 
Hearing Aid 
Not covered 
Not covered 
Not covered 
Not covered 
Not covered 
1 exam per year 
Routine Vision Exam  
Not covered 
$5 
$5 
$5 
$5/1 exam per year 
1 exam per year 
Routine Physical Exams 
Not covered 
$5 
$5 
$5 
$5 
 
Routine Podiatry Exam  
Not covered 
$5 
$5 
$5 
$5 
 
Routine Chiropractor  
Not covered 
Not covered 
Not covered 
Not covered 
Not covered 
 
Health Education/Wellness 
Not covered 
Not covered 
Not covered 
Not covered 
Not covered 
 
Transportation (routine) 
Not covered 
Not covered 
Not covered 
Not covered 
Not covered 
 
Acupuncture 
Not covered 
Not covered 
Not covered 
Not covered 
Not covered 
 
Prescription Drugs 10/20 
Formulary Generic Maximum  
 
Unlimited 
Unlimited 
Unlimited 
Unlimited 
 
Formulary Brand Maximum 
 
$500/year 
$1,500/year 
Unlimited 
Unlimited 
 
Non-formulary Brand Maximum 
 
Not covered 
Not covered 
Not covered 
Unlimited 
 
Retail (30-day supply) 
           
- Formulary Generic 
 
$10 
$10 
$10 
$10 
 
- Formulary Brand 
 
$20 
$20 
$20 
$20 
 
- Non-formulary Brand 
 
Not covered 
Not covered 
Not covered 
$50 
 
Mail-order (90-day supply) 
           
- Formulary Generic 
 
$20 
$20 
$20 
$20 
 
- Formulary Brand 
 
$40 
$40 
$40 
$40 
 
- Non-formulary Brand 
 
Not covered 
Not covered 
Not covered 
$100 
 
Prescription Drugs 15/30 
Formulary Generic Maximum  
 
Unlimited 
Unlimited 
Unlimited 
Unlimited 
 
Formulary Brand Maximum 
 
$500/year 
$1,500/year 
Unlimited 
Unlimited 
 
Non-formulary Brand Maximum 
 
Not covered 
Not covered 
Not covered 
Unlimited 
 
Retail (30-day supply) 
           
- Formulary Generic 
 
$15 
$15 
$15 
$15 
 
- Formulary Brand 
 
$30 
$30 
$30 
$30 
 
- Non-formulary Brand 
 
Not covered 
Not covered 
Not covered 
$50 
 
Mail-order (90-day supply) 
           
- Formulary Generic 
 
$30 
$30 
$30 
$30 
 
- Formulary Brand 
 
$60 
$60 
$60 
$60 
 
- Non-formulary Brand 
 
Not covered 
Not covered 
Not covered 
$100 
 
IA-2004-149-6P
2/2004 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, 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 (excluding 30 counties in the Kansas City area): 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. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: 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 area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees 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. Use of the Anthem Web sites constitutes your agreement with our Terms of Use