WIXLIB

Finding Your Monthly PremiumPlans A, F, G & N Effective March 1, 2017Premiums are subject to change. Premium is based upon your tobacco usage, age, areaand plan.( continued)Step 2: Find Your PremiumTable 2 For Tobacco Users. this table if: you have used tobacco products in the past 12 months. (If you are not a tobaccoUseuser, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table 1.)Age*Areas 1, 2 and 3Plan APlan FPlan GPlan N 65656667686970717273747576777879 7.15152.98159.03165.29 47 7.7 917 5 .41182.55189.92197. 5 190.53198.03 290.20121.69126.63131.74137. 0 3142.54148.23154.15160.25166.62173 . 21180.03171. 213.91222.30230.96187. 1 2194.46202.09209.968081 200.29208.31314.483 27. 07239.97249.57218.15226.88* Attained age at the time of enrollment.2017 Outline of Medicare Supplement Coverage(see next page for more areas)11

Finding Your Monthly PremiumPlans A, F, G & N Effective March 1, 2017Premiums are subject to change. Premium is based upon your tobacco usage, age, areaand plan.( continued)Step 2: Find Your PremiumTable 2 For Tobacco Users. this table if: you have used tobacco products in the past 12 months. (If you are not a tobaccoUseuser, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table 1.)Age*Areas 4 and 5Plan APlan FPlan GPlan N 65656667686970717273747576777879 344.94141.31147. 0 09.05 0.49291.61303.14315.08N/A161.73168.30175 .11182.14189.45197. 0 2204.89213.00221.46230.22239.29 403.33147. 0 3153.00159.19165.58172. 2 3179 .11186.26193.64201.33209.29217. 5 4217. 2 9225.80234.64243.813 27.4 8340.31353.653 67.4 081 253.31263.453 81.783 97. 07289.95301.55263.59274 .14* Attained age at the time of enrollment.2017 Outline of Medicare Supplement Coverage12

Finding Your Monthly PremiumPlans A, F, G & N Effective March 1, 2017Premiums are subject to change. Premium is based upon your tobacco usage, age, areaand plan.( continued)Step 2: Find Your PremiumTable 2 For Tobacco Users. this table if: you have used tobacco products in the past 12 months. (If you are not a tobaccoUseuser, are in your Open Enrollment Period, or are eligible for Guaranteed Issue, see Table 1.)Age*Area 6Plan APlan FPlan GPlan N 65656667686970717273747576777879 5.88182.86190.09197. 57 526.3818 8 9268.71279.29N/A142.96148.76154.77161.00167.4 6174 .15181.09188.28195.76203.50211.51 309.92129.96135.2414 0 .7 0146.36152.24158.32164.63171.16177. 9 13.48325.74219.82228.462 37.41246.68199.842 07. 6 9215.83224.258081 239.40248.98338.42351.96256.29266.54232.99242.31* Attained age at the time of enrollment.2017 Outline of Medicare Supplement Coverage13

Important Plan DisclosuresPlans A, F, G & NRetain this outline for your records.DisclosuresNoticeUse this outline to compare benefits andpremiums among policies.This policy may not fully cover all of yourmedical costs.Medicare deductibles and coinsuranceamounts are effective as of January 1, 2017.Medicare may change their amounts annually.Neither Anthem Blue Cross nor its agents areconnected with Medicare.Read Your Policy Very CarefullyThis is only an outline describing your policy’smost important features. The policy is yourinsurance contract. You must read the policyitself to understand all of the rights and dutiesof both you and Anthem Blue Cross.Right to Return PolicyIf you find that you are not satisfied withyour policy, you may return it to us at ourAdministrative Office: P.O. Box 659816, SanAntonio, TX 78265-9116. If you send the policyback to us within 30 days after you receive it,we will treat the policy as if it had never beenissued and return all of your payments.This outline of coverage does not give allthe details of Medicare coverage. Contactyour local Social Security Office or consultMedicare and You for more details.Complete Answers are Very ImportantWhen you fill out the application for thenew policy, be sure to answer truthfully andcompletely all questions about yourmedical and health history. The companymay cancel your policy and refuse to pay anyclaims if you leave out or falsify importantmedical information.Review the application carefully before yousign it. Be certain that all information hasbeen properly recorded.Policy ReplacementIf you are replacing another health insurancepolicy, do NOT cancel it until you have actuallyreceived your new policy and are sure youwant to keep it.2017 Outline of Medicare Supplement Coverage14

KY ONLY will need to place the extra disclaimer:(1 Plan A is not available as a Select Plan option.)Plan AMedicare (Part A) – Hospital Services – Per Benefit PeriodServicesWMedicare PaysPlan PaysYou PayHospitalization*Semiprivate room and board, general nursing and miscellaneous services and suppliesFirst 60 daysAll but 1,316 0 1,316(Part A deductible)61st thru 90th dayAll but 329 a day 329 a day 0All but 658 a day 658 a day 0— Additional365 days 0100% of Medicareeligible expenses 0**— Beyond the additional365 days 0 0All costsst91 day and after:t While using 60 lifetimereserve daystWOnce lifetime reservedays are used:Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least 3 days andentered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 daysAll approved amounts 0 021 thru 100 dayAll but 164.50 a day 0Up to 164.50 a day101st day and after 0 0All costsFirst 3 pints 03 pints 0Additional amounts100% 0 0stWWthBloodHospice CareYou must meet Medicare’srequirements, including a doctor’scertification of terminal illnessAll but very limitedMedicarecopayment/copayment/coinsurance forcoinsuranceoutpatient drugs andinpatient respite care 0* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after youhave been out of the hospital and have not received skilled care in any other facility for 60 days in a row.** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place ofMedicare and will pay whatever amount Medicare would have paid for up to an additional 365 days asprovided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for thebalance based on any difference between its billed charges and the amount Medicare would have paid.2017 Outline of Medicare Supplement Coverage15

KY ONLY will need to place the extra disclaimer:(1 Plan A is not available as a Select Plan option.)Plan A( continued)Medicare (Part B) – Medical Services – Per Calendar YearServicesWMedicare PaysPlan PaysYou PayMedical Expenses — In or Out of the Hospital and Outpatient Hospital Treatment, such asphysician’s services, inpatient and outpatient medical and surgical services and supplies, physicaland speech therapy, diagnostic tests, durable medical equipmentFirst 183 of MedicareApproved Amounts* 0 0 183(Part B deductible)Remainder of MedicareApproved AmountsGenerally 80%Generally 20% 0 0All costsWPart B Excess ChargesAbove Medicare Approved Amounts 0WBloodFirst 3 pints 0All costs 0Next 183 of MedicareApproved Amounts* 0 0 183(Part B deductible)Remainder of MedicareApproved Amounts80%20% 0100% 0 0WClinical Laboratory ServicesTests for Diagnostic ServicesParts A & B ServicesMedicare PaysServicesWttPlan PaysYou PayHome Health Care — Medicare Approved ServicesMedically necessaryskilled care servicesand medical supplies100% 0 0— First 183 of Medicareapproved amounts* 0 0 183(Part B deductible)— Remainder of Medicareapproved amounts80%20% 0Durable medical equipment:* Once you have been billed 183 of Medicare-approved amounts for covered services(which are noted with an asterisk), your Part B deductible will have been met for the calendar year.2017 Outline of Medicare Supplement Coverage16

Plan FMedicare (Part A) – Hospital Services – Per Benefit PeriodServicesWMedicare PaysPlan PaysYou PayHospitalization*Semiprivate room and board, general nursing and miscellaneous services and suppliesFirst 60 daysAll but 1,316 1,316(Part A deductible) 061st thru 90th dayAll but 329 a day 329 a day 0All but 658 a day 658 a day 0— Additional365 days 0100% of Medicareeligible expenses 0**— Beyond the additional365 days 0 0All costsst91 day and after:t While using 60 lifetimereserve daystWOnce lifetime reservedays are used:Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least 3 daysand entered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 daysAll approved amounts 0 021 thru 100 dayAll but 164.50 a dayUp to 164.50 a day 0101st day and after 0 0All costsFirst 3 pints 03 pints 0Additional amounts100% 0 0stWWthBloodHospice CareYou must meet Medicare’srequirements, including a doctor’scertification of terminal illnessAll but very limitedMedicarecopayment/copayment/coinsurance forcoinsuranceoutpatient drugs andinpatient respite care 0* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after youhave been out of the hospital and have not received skilled care in any other facility for 60 days in a row.** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place ofMedicare and will pay whatever amount Medicare would have paid for up to an additional 365 days asprovided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for thebalance based on any difference between its billed charges and the amount Medicare would have paid.2017 Outline of Medicare Supplement Coverage17

Plan F( continued)Medicare (Part B) – Medical Services – Per Calendar YearServicesWMedicare PaysPlan PaysYou PayMedical Expenses — In or Out of the Hospital and Outpatient Hospital Treatment, such asphysician’s services, inpatient and outpatient medical and surgical services and supplies, physicaland speech therapy, diagnostic tests, durable medical equipmentFirst 183 of Medicare ApprovedAmounts* 0 183(Part B deductible) 0Remainder of MedicareApproved AmountsGenerally 80%Generally 20% 0100% 0All costs 0Next 183 of Medicare Approved 0Amounts* 183(Part B deductible) 0Remainder of MedicareApproved Amounts80%20% 0100% 0 0WPart B Excess ChargesAbove Medicare Approved Amounts 0WBloodFirst 3 pintsW 0Clinical Laboratory ServicesTests for Diagnostic ServicesParts A & B ServicesServicesWttMedicare PaysPlan PaysYou PayHome Health Care — Medicare Approved ServicesMedically necessary skilledcare services and medicalsupplies100% 0 0— First 183 of MedicareApproved Amounts* 0 183(Part B deductible) 0— Remainder of Medicareapproved amounts80%20% 0Durable medical equipment:* Once you have been billed 183 of Medicare-approved amounts for covered services(which are noted with an asterisk), your Part B deductible will have been met for the calendar year.2017 Outline of Medicare Supplement Coverage18

Plan F( continued)Other Benefits – Not Covered by MedicareServicesWMedicare PaysPlan PaysYou PayForeign Travel — Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each tripoutside the USAFirst 250 each calendar year 0 0 250Remainder of Charges 080% to a lifetimemaximum benefit of 50,00020% and amountsover the 50,000lifetime maximum2017 Outline of Medicare Supplement Coverage19

Plan GMedicare (Part A) – Hospital Services – Per Benefit PeriodServicesWMedicare PaysPlan PaysYou PayHospitalization*Semiprivate room and board, general nursing and miscellaneous services and suppliesFirst 60 daysAll but 1,316 1,316(Part A deductible) 061st thru 90th dayAll but 329 a day 329 a day 0All but 658 a day 658 a day 0— Additional365 days 0100% of Medicareeligible expenses 0**— Beyond the additional365 days 0 0All costsst91 day and after:t While using 60 lifetimereserve daystWOnce lifetime reservedays are used:Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least 3 days andentered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 daysAll approved amounts 0 021 thru 100 dayAll but 164.50 a dayUp to 164.50 a day 0101st day and after 0 0All costsFirst 3 pints 03 pints 0Additional amounts100% 0 0stWWthBloodHospice CareYou must meet Medicare’srequirements, including a doctor’scertification of terminal illnessAll but very limitedMedicare copayment/ 0copayment/coinsurancecoinsurance foroutpatient drugs andinpatient respite care* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after youhave been out of the hospital and have not received skilled care in any other facility for 60 days in a row.** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place ofMedicare and will pay whatever amount Medicare would have paid for up to an additional 365 days asprovided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for thebalance based on any difference between its billed charges and the amount Medicare would have paid.2017 Outline of Medicare Supplement Coverage20

Plan G( continued)Medicare (Part B) – Medical Services – Per Calendar YearServicesWMedicare PaysPlan PaysYou PayMedical Expenses — In or Out of the Hospital and Outpatient Hospital Treatment, such asphysician’s services, inpatient and outpatient medical and surgical services and supplies, physicaland speech therapy, diagnostic tests, durable medical equipmentFirst 183 of Medicare ApprovedAmounts* 0 0 183(Part B deductible)Remainder of MedicareApproved AmountsGenerally 80%Generally 20% 0100% 0All costs 0 0 183(Part B deductible)20% 0 0 0WPart B Excess ChargesAbove Medicare Approved Amounts 0WBloodFirst 3 pints 0Next 183 of Medicare Approved 0Amounts*Remainder of Medicare80%Approved AmountsWClinical Laboratory ServicesTests for Diagnostic Services100%Parts A & B ServicesServicesWttMedicare PaysPlan PaysYou PayHome Health Care — Medicare Approved ServicesMedically necessary skilledcare services and medicalsupplies100% 0 0— First 183 of MedicareApproved Amounts* 0 0 183(Part B deductible)— Remainder of Medicareapproved amounts80%20% 0Durable medical equipment:* Once you have been billed 183 of Medicare-approved amounts for covered services(which are noted with an asterisk), your Part B deductible will have been met for the calendar year.2017 Outline of Medicare Supplement Coverage21

Plan G( continued)Other Benefits – Not Covered by MedicareServicesWMedicare PaysPlan PaysYou PayForeign Travel — Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each tripoutside the USAFirst 250 each calendar year 0 0 250Remainder of Charges 080% to a lifetimemaximum benefitof 50,00020% and amountsover the 50,000lifetime maximum2017 Outline of Medicare Supplement Coverage22

Plan NMedicare (Part A) – Hospital Services – Per Benefit PeriodServicesWMedicare PaysPlan PaysYou PayHospitalization*Semiprivate room and board, general nursing and miscellaneous services and suppliesFirst 60 daysAll but 1,316 1,316(Part A deductible) 061st thru 90th dayAll but 329 a day 329 a day 0All but 658 a day 658 a day 0— Additional365 days 0100% of Medicareeligible expenses 0**— Beyond the additional365 days 0 0All costsst91 day and after:t While using 60 lifetimereserve daystWOnce lifetime reservedays are used:Skilled Nursing Facility Care*You must meet Medicare’s requirements, including having been in a hospital for at least 3 days andentered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 daysAll approved amounts 0 021 thru

Medicare Supplement Outline of Coverage Plans A, F, G & N Anthem Blue Cross . Call toll-free 1-800-333-3883 with questions. Administrative Office: P.O. Box 659816, San Antonio, TX 78265-9116 . AOOC001M(15)-CA . Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010 . not go through medical underwriting and are