Administrative Office: P.O. Box , San Antonio, TX Toll Free Telephone Number:

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OOC_MS_OH_WPOOC001M-AFGN-210329-MACRA-2021rates-2021mnocs_CIC March 29, 2021 12:24 PM

Administrative Office: P.O. Box 659816, San Antonio, TX 78265–9116 Toll Free Telephone Number: 1-866-803-5169

Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020 This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available.

Only applicants’ first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. We offer Plans A, F, G, N, Select F, Select G and Select N.

Note: A Pmeans 100% of the benefit is paid.

Benefits Plans Available to All Applicants

A B D G

¹

K L M N

Medicare Part A coinsurance and

hospital coverage (up to an additional 365 days

after Medicare benefits are used up)

P P P P P P P P

Medicare Part B coinsurance

or copayment

P P P P

⁵⁰^% ⁷⁵^%

P

^copays_apply^P₃

Blood

(first three pints)

P P P P

⁵⁰^% ⁷⁵^%

P P

Part A hospice care coinsurance

or copayment

P P P P

⁵⁰^% ⁷⁵^%

P P

Skilled nursing facility coinsurance

P P

⁵⁰^% ⁷⁵^%

P P

Medicare Part A deductible

P P P

⁵⁰^% ⁷⁵^% ⁵⁰^%

P

Medicare Part B deductible Medicare Part B

excess charges

P

Foreign travel emergency

(up to plan limits)

P P

$6,220² $3,110²

P P

Out-of-pocket limit in 2021²

Medicare first eligible before 2020 only

C F

¹

P P P P P P P P P P P P P P P P P

1 Plans F and G also have a high deductible options which require first paying a plan deductible of $2,370 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

AOOC001M(19)-OH 75801OHSENABS (Rev. 03_2021)

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2

Monthly Premium

Premiums are subject to change.

Plans A, F, G & N | Effective July 1, 2021

Premium is based upon your age, gender, area and plan.

FIND YOUR PREMIUM (continued)

* Attained age at the time of enrollment.

AREA 1

Age* MALE FEMALE

Plan A Plan F Plan G Plan N Plan A Plan F Plan G Plan N 65 $130.46 $184.86 $122.83 $125.15 $118.91 $168.51 $111.96 $114.07 66 133.83 196.00 130.23 132.70 121.99 178.66 118.72 120.96 67 136.73 207.14 137.63 140.24 124.62 188.81 125.45 127.82 68 142.94 218.27 145.04 147.79 130.28 198.96 132.21 134.70 69 149.07 229.41 152.43 155.32 135.88 209.12 138.95 141.56 70 155.57 240.55 159.84 162.86 141.79 219.27 145.69 148.44 71 162.03 251.70 167.23 170.40 147.69 229.42 152.44 155.33 72 168.41 262.82 174.64 177.94 153.50 239.58 159.18 162.20 73 174.88 273.97 182.04 185.49 159.41 249.73 165.93 169.08 74 181.24 285.10 189.44 193.03 165.21 259.88 172.68 175.95 75 187.10 296.24 196.83 200.56 170.53 270.03 179.42 182.82 76 192.95 305.98 204.24 208.10 175.88 278.91 186.17 189.69 77 198.79 315.25 211.63 215.64 181.20 287.36 192.91 196.56 78 204.63 324.54 219.05 223.20 186.53 295.83 199.68 203.45 79 210.09 333.23 226.45 230.72 191.51 303.74 206.41 210.31 80

81+ 214.97

219.01 340.85

347.33 233.84

233.84 238.27

238.27 195.95

199.64 310.70

316.59 213.16

213.16 217.19 217.19

n Area 1: Allen, Ashland, Athens, Auglaize, Belmont, Champaign, Clark, Clinton, Coshocton, Crawford, Defiance, Delaware, Fairfield, Fayette, Franklin, Gallia, Greene, Guernsey, Hancock, Hardin, Henry, Hocking, Holmes, Huron, Jefferson, Knox, Lawrence, Licking, Logan, Madison, Marion, Meigs, Mercer, Miami, Monroe, Morgan, Morrow, Muskingum, Noble, Paulding, Perry, Pickaway, Putnam, Richland, Ross, Seneca, Shelby, Union, Van Wert, Washington, Wayne, Williams, Wyandot

(SEE NEXT PAGE FOR MORE AREAS)

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3

Monthly Premium

Plans A, F, G & N | Effective July 1, 2021

AREA 2

81+ 228.29

232.60 361.99

368.86 248.34

248.34 253.04

253.04 208.10

212.02 329.97

336.22 226.37

226.37 230.65 230.65

n Area 2: Adams, Brown, Butler, Clermont, Darke, Hamilton, Highland, Jackson, Montgomery, Pike, Preble, Scioto, Vinton, Warren

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4

Monthly Premium

Plans A, F, G & N | Effective July 1, 2021

AREA 3

81+ 243.24

247.82 385.69

393.02 264.61

264.61 269.62

269.62 221.73

225.89 351.57

358.24 241.20

241.20 245.77 245.77

n Area 3: Ashtabula, Carroll, Columbiana, Cuyahoga, Erie, Fulton, Geauga, Harrison, Lake, Lorain, Lucas, Mahoning, Medina, Ottawa, Portage, Sandusky, Stark, Summit, Trumbull, Tuscarawas, Wood

(SEE NEXT PAGE FOR SELECT PLANS)

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5

Monthly Premium

Plans F, G & N | Effective July 1, 2021

Select Plans require use of a network hospital. Premium is based upon your age, gender, area and plan.

FIND YOUR PREMIUM SELECT PLANS (continued)

AREA 1

Plan F Plan G Plan N Plan F Plan G Plan N

65 $182.06 $108.96 $104.01 $165.94 $ 99.32 $ 94.81

66 193.01 115.54 110.28 175.93 105.32 100.54

67 203.98 122.10 116.55 185.94 111.30 106.23

68 214.94 128.68 122.82 195.93 117.29 111.96

69 225.91 135.22 129.08 205.94 123.27 117.66

70 236.90 141.80 135.34 215.93 129.25 123.36

71 247.87 148.37 141.63 225.93 135.23 129.10

72 258.83 154.93 147.89 235.92 141.21 134.80

73 269.79 161.48 154.15 245.92 147.21 140.52

74 280.75 168.06 160.42 255.93 153.19 146.22

75 291.74 174.61 166.69 265.92 159.17 151.91

76 301.32 181.19 172.95 274.66 165.16 157.65

77 310.45 187.76 179.21 282.99 171.14 163.36

78 319.60 194.34 185.51 291.32 177.14 169.07

79 328.16 200.89 191.74 299.11 183.10 174.78

80 335.66 207.46 198.03 305.98 189.10 180.51

81⁺ 342.05 207.46 198.03 311.78 189.10 180.51

n Area 1: Allen, Ashland, Athens, Auglaize, Belmont, Champaign, Clark, Clinton, Coshocton, Crawford, Defiance, Delaware, Fairfield, Fayette, Franklin, Gallia, Greene, Guernsey, Hancock, Hardin, Henry, Hocking, Holmes, Huron, Jefferson, Knox, Lawrence, Licking, Logan, Madison, Marion, Meigs, Mercer, Miami, Monroe, Morgan, Morrow, Muskingum, Noble, Paulding, Perry, Pickaway, Putnam, Richland, Ross, Seneca, Shelby, Union, Van Wert, Washington, Wayne, Williams, Wyandot

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6

Monthly Premium

Plans F, G & N | Effective July 1, 2021

AREA 2

65 $193.34 $115.71 $110.45 $176.25 $105.50 $100.69

66 204.98 122.71 117.13 186.86 111.84 106.76

67 216.65 129.67 123.77 197.48 118.19 112.82

68 228.29 136.66 130.44 208.08 124.56 118.90

69 239.93 143.61 137.08 218.70 130.92 124.95

70 251.57 150.59 143.75 229.32 137.28 131.03

71 263.25 157.57 150.41 239.94 143.63 137.09

72 274.88 164.52 157.05 250.55 149.98 143.17

73 286.53 171.52 163.71 261.17 156.34 149.23

74 298.17 178.48 170.38 271.78 162.69 155.29

75 309.82 185.46 177.03 282.41 169.05 161.36

76 320.01 192.42 183.66 291.70 175.40 167.42

77 329.71 199.38 190.31 300.54 181.74 173.47

78 339.44 206.38 197.00 309.38 188.12 179.57

79 348.51 213.34 203.64 317.68 194.47 185.62

80 356.48 220.32 210.30 324.94 200.83 191.70

81⁺ 363.25 220.32 210.30 331.12 200.83 191.70

n Area 2: Adams, Brown, Butler, Clermont, Darke, Hamilton, Highland, Jackson, Montgomery, Pike, Preble, Scioto, Vinton, Warren

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7

Monthly Premium

Plans F, G & N | Effective July 1, 2021

AREA 3

65 $206.01 $123.29 $117.68 $187.78 $112.39 $107.27

66 218.42 130.73 124.79 199.09 119.18 113.76

67 230.83 138.15 131.87 210.40 125.94 120.20

68 243.24 145.59 138.97 221.71 132.70 126.67

69 255.66 153.01 146.05 233.02 139.47 133.14

70 268.07 160.46 153.16 244.34 146.26 139.61

71 280.48 167.88 160.23 255.66 153.02 146.07

72 292.87 175.31 167.32 266.95 159.81 152.53

73 305.29 182.73 174.42 278.28 166.58 159.00

74 317.69 190.16 181.52 289.59 173.34 165.45

75 330.11 197.59 188.61 300.91 180.10 171.92

76 340.96 205.03 195.71 310.80 186.88 178.38

77 351.29 212.45 202.79 320.21 193.65 184.84

78 361.66 219.90 209.89 329.64 200.44 191.32

79 371.33 227.32 216.96 338.48 207.21 197.79

80 379.81 234.76 224.09 346.23 213.97 204.26

81⁺ 387.04 234.76 224.09 352.80 213.97 204.26

n Area 3: Ashtabula, Carroll, Columbiana, Cuyahoga, Erie, Fulton, Geauga, Harrison, Lake, Lorain, Lucas, Mahoning, Medina, Ottawa, Portage, Sandusky, Stark, Summit, Trumbull, Tuscarawas, Wood

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8

PREMIUM INFORMATION

We, Anthem, can only raise your premium if we raise the premium for all policies like yours in this State.

We will recalculate your age each year to determine your new attained age. Your premium may increase annually at your plan renewal based upon your new attained age.

TOBACCO Anthem does not offer tobacco rates.

HOUSEHOLD DISCOUNT

A 5% multi-insured discount will apply to Insureds who reside with at least one other active Anthem Medicare supplement Insured within a household. The discount will apply only while this criterion is met.

This discount will be offered to eligible Insureds and when the Insured is no longer eligible, the discount will be discontinued.

DISCLOSURES

Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY

This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to us at our Administrative Office:

P.O. Box 659816, San Antonio, TX 78265-9116. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

POLICY REPLACEMENT

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE This policy may not fully cover all of your medical costs.

Neither Anthem nor its agents are connected with Medicare.

This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult “Medicare & You” for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

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9 GRIEVANCE PROCEDURES

The following terms when used in this procedure have the meanings shown below.

“Adverse Benefit Determination” is a denial, reduction, or failure to make payment (in whole or in part) of a claim due to lack of eligibility for coverage, policy limitations or exclusions, or a determination that an item or service otherwise covered is experimental or investigational or not Medically Necessary or appropriate. The application of copayments or deductibles is not considered a denial of a claim.

“Authorized Representative” is a person granted authority by You and us to act on Your behalf regarding a claim for benefit or a grievance of an Adverse Benefit Determination.

An assignment of benefits is not a grant of authority to act on Your behalf in pursuing and appealing a benefit determination.

If You are dissatisfied with our benefit determination on a claim, You may appeal our decision by following the steps outlined in this procedure. We will resolve Your grievance in a thorough, appropriate, and timely manner to ensure that You are afforded a full and fair review of claims for benefits. Benefit determinations will be made in accordance with the Policy and consistently among claimants. Your Authorized Representative may submit written comments, documents, records and other information relating to claims or grievances. We will provide a review that takes into account all information submitted whether or not it was considered with its first determination on the claim. Any notifications by us required under these procedures will be supplied to Your Authorized Representative.

Your Authorized Representative may file a grievance with us within 180 days of receipt of an Adverse Benefit Determination. To file a grievance, telephone the toll-free number listed in this Policy.

We will review the claim and notify You of our decision within 60 days of the grievance. Any

medical advisor involved in reviewing the grievance will be different from and not in a subordinate position to the medical advisor involved in the initial benefit determination.

Notice of the grievance decision will include the following in written or electronic form:

a) the specific reason for the grievance decision;

b) reference to the Policy provisions on which the decision was based;

c) a statement that You are entitled to receive upon request and free of charge, reasonable accessibility to and copies of all relevant documents, records, and criteria including an explanation of clinical judgment on which the decision was based and identification of the medical experts;

d) If You wish to dispute our decision on a claim, You may register a complaint by submitting the complaint to the following address. In reviewing, the complaint, we follow the complaint procedure described in this provision.

Community Insurance Company 4361 Irwin Simpson Rd, Mason OH, 45040

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10 e) If Your claim has been denied on the basis that the services is not Medically Necessary, or You

have been diagnosed with a terminal condition and the service has been denied on the basis that it is experimental or investigative, You may have a right to request an independent review by an outside medical practitioner. Submit such request in writing to the following address and arrangements will be made for You:

Community Insurance Company 4361 Irwin Simpson Rd, Mason OH, 45040

f) If Your claim has been denied on the basis that it is not a Covered Service, You have the right to file a complaint with the Ohio Department of Insurance at the address below or the complaint may also be filed via the Internet at http://insurance.ohio.gov.

FOR CONSUMERS: Ohio Department of Insurance Consumer Services Division 50 West Town Street

Third Floor – Suite 300 Columbus, OH 43215 (614) 644-2673

Toll free in Ohio 1-800-686-1526

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11

PLAN A

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,484 $0 $1,484 (Part A

deductible) 61^st thru 90^th day

91^stday and after:

All but $371 a day $371 a day $0 — While using 60 lifetime

reserve days

— Once lifetime reserve days are used:

All but $742 a day $742 a day $0

— Additional

365 days $0 100% of Medicare

eligible expenses $0**

— Beyond the additional

365 days $0 $0 All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21^st thru 100^th day All but $185.50 a day $0 Up to $185.50 a day

101^st day and after $0 $0 All costs

BLOOD First 3 pints

Additional amounts

$0 100%

3 pints

$0

$0 HOSPICE CARE

You must meet Medicare’s All but very limited Medicare copayment/ $0 requirements, including a doctor’s copayment/ coinsurance

certification of terminal illness coinsurance for outpatient drugs and inpatient respite care

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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12

PLAN A

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $203 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.

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare Approved Amounts*

Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

$203 (Part B deductible)

$0 Part B Excess Charges

(Above Medicare Approved Amounts)

$0 $0 All costs

Next $203 of Medicare Approved Amounts*

$0

$0 80%

All costs

$0 20%

$0

$0 CLINICAL LABORATORY SERVICES

-TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

PARTS A & B HOME HEALTH CARE —

MEDICARE APPROVED SERVICES — Medically necessary skilled

care services and medical 100% $0 $0

supplies

— Durable medical equipment:

First $203 of Medicare

approved amounts* $0 $0 $203 (Part B

deductible) Remainder of Medicare

approved amounts 80% 20% $0

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13

PLAN F

HOSPITALIZATION*

First 60 days All but $1,484 $1,484 (Part A

deductible) $0

61^st thru 90^th day 91^stday and after:

reserve days

All but $742 a day $742 a day $0

— Additional

365 days $0 100% of Medicare

365 days $0 $0 All costs

SKILLED NURSING FACILITY CARE*

21^st thru 100^th day All but $185.50 a day Up to $185.50 a day $0

$0 100%

3 pints

$0

$0 HOSPICE CARE

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “core benefits”. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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14

PLAN F

$0

Generally 80%

$203 (Part B deductible) Generally 20%

$0

(Above Medicare Approved Amounts) $0 100% $0

$0

$0 80%

All costs

$203 (Part B deductible) 20%

$0

100% $0 $0

PARTS A & B

HOME HEALTH CARE —

care services and medical supplies

First $203 of Medicare approved amounts*

Remainder of Medicare approved amounts

100%

$0 80%

$0

$203 (Part B deductible) 20%

$0

$0 OTHER BENEFITS – NOT COVERED BY MEDICARE FOREIGN TRAVEL —

NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

80% to a lifetime 20% and amounts Remainder of Charges $0 maximum benefit of over the $50,000

$50,000 lifetime maximum

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15

PLAN G

HOSPITALIZATION*

First 60 days All but $1,484 $1,484

(Part A deductible) $0 61^st thru 90^th day

91^stday and after:

reserve days

All but $742 a day $742 a day $0

— Additional

365 days $0 100% of Medicare

365 days $0 $0 All costs

21^st thru 100^th day All but $185.50 a day Up to $185.50 a day $0

$0 100%

3 pints

$0

$0 HOSPICE CARE

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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16

PLAN G

$0

Generally 80%

$0

Generally 20%

$203

(Part B deductible)

(Above Medicare Approved Amounts) $0 100% $0

$0

$0 80%

All costs

$0 20%

$0

$203

100% $0 $0

PARTS A & B

100%

$0 80%

$0

$0 20%

$0

$203

80% to a lifetime 20% and amounts

Remainder of Charges $0 maximum benefit of over the $50,000

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17

PLAN N

HOSPITALIZATION*

First 60 days All but $1,484 $1,484 (Part A

deductible) $0

61^st thru 90^th day 91^stday and after:

reserve days

All but $742 a day $742 a day $0

— Additional

365 days $0 100% of Medicare

365 days $0 $0 All costs

21^st thru 100^th day All but $185.50 a day Up to $185.50 a day $0

$0 100%

3 pints

$0

$0 HOSPICE CARE

** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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18

PLAN N

MEDICAL EXPENSES — IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare

Approved Amounts* $0 $0 $203 (Part B

deductible) Remainder of Medicare Approved

Amounts Generally 80% Balance, other than

up to $20 per office visit and up to $50 per emergency room visit. The co- payment of up to

$50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to

$50 per emergency room visit. The co- payment of up to

$50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Part B Excess Charges

(Above Medicare Approved Amounts) $0 $0 All costs

BLOOD

First 3 pints $0 All costs $0

Next $203 of Medicare

Approved Amounts* $0 $0 $203 (Part B

deductible) Remainder of Medicare Approved

Amounts 80% 20% $0

CLINICAL LABORATORY SERVICES -TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

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19

PLAN N

(continued)

PARTS A & B

100%

$0 80%

$0

$0 20%

$0

80% to a lifetime 20% and amounts Remainder of Charges $0 maximum benefit of over the $50,000