Medical Plan Highlights

Individual Medicare Supplement plans for residents of Washington state (excluding Clark County)

BHBMSWA (01-2018)

MEDICARE SUPPLEMENT

For more in-depth information, please refer to the Medicare Supplement Outline of Coverage.

You can count on us

Premera Blue Cross Medicare Supplement plans make it easy for you to get the care you need. With these plans, you can count on having:

Freedom to use any doctor or hospital that accepts Medicare

A plan thats guaranteed renewable and portable

Coverage that wont be terminated if your health changes

Nationwide coverage when you travel

Our Medicare Supplement plans are easy to use, and we make it simple for you to understand your benefits and costs. They cover the growing costs of Original Medicare and give you the freedom to see any doctor who accepts Medicare.

Premera Blue Cross has been a trusted name in healthcare in the Northwest for more than 80 years. Use the expertise of our highly trained, local representatives to assist you in choosing the plan thats right for you. And know that if you ever have questions about the best way to use your plan, were here to help.

Youve worked hard to act any age you want. Now is the time when freedom is yours.PREMERA BLUE CROSS MEDICARE SUPPLEMENT PLANS HELP YOU ENJOY IT

A Medicare Supplement plan can help pay some of the healthcare costs that Original Medicare doesnt cover, like copayments, coinsurance, and deductibles. Some Medicare Supplement plans also offer coverage for services that Original Medicare doesnt cover, like medical care

when you travel outside of the United States. If you have Original Medicare and you buy a Medicare Supplement plan, Medicare will pay its share of the Medicare-approved amount for covered healthcare costs. Then your Medicare Supplement plan pays its share.

Premera Medicare Supplement Plans

WITH FIVE PLAN OPTIONS, ITS EASY TO FIND THE PLAN THAT IS RIGHT FOR YOU.

Rates as low as $172 a monthA plan with basic coveragePlan A provides coverage for those with fewer hospital and physician expenses.

Plan A

Rates as low as $185 a monthOur newest plan optionPlan G offers the same great benefits as Plan F. However, Plan G doesnt cover the Medicare Part B deductible so youll pay that cost if you choose Plan G.

Plan G

Rates as low as $216 a monthOur most popular planPlan F provides 100% coverage for Medicare covered services. That means no copayments, coinsurance, or deductibles.

Plan F

Rates as low as $170 a monthCoverage with a copay100% coverage on all Medicare-covered inpatient hospital services. After youve met your Part B deductible, you pay a copay for office visits and emergency room visits.

Plan N

Rates as low as $89 a month

Like Plan F, but with a high deductible and a lower monthly rateA nice fit if you prefer a high deductible health plan. You can use funds in an existing HSA (Health Savings Account) to pay for medical expenses applied to your deductible.

High Deductible Plan F

Policy form numbers: Plan A 021190 (06-2010), 021194 (06-2010) Plan F 021192 (06-2010), 021196 (06-2010)

*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.

Discover A MEDICARE SUPPLEMENT PLAN THATS RIGHT FOR YOU

Plan details Plan ABasic coverage

Plan FOur most popular plan

Monthly rates are $5 more if you choose not to enroll in our Automatic Funds Transfer (AFT) program

Monthly rate $172 $216

Plan summary Your costs: Your costs:

Doctor/hospital choice Any doctor or hospital that accepts MedicareAny doctor or hospital that

accepts Medicare

Deductibles Hospital - Part A: $1,340Medical - Part B: $183 $0

Office visit $0 after Part B deductible $0

Inpatient hospital care $0 after Part A deductible(per benefit period*) $0

Skilled nursing facility$0/day (days 120)

$167.50/day (days 21100)All costs (days 101+)

$0/day (days 1100)All costs (days 101+)

Outpatient hospital care $0 after Part B deductible $0Ambulance $0 after Part B deductible $0Emergency care $0 after Part B deductible $0Urgent care $0 after Part B deductible $0Durable medical equipment $0 after Part B deductible $0Outpatient lab/x-rays $0 after Part B deductible $0

Part B excess charges (above Medicare approved amounts) Not covered $0

Home health care $0 $0Hospice $0 $0

Foreign travel coverage (not covered by Medicare)

First $250 in charges (per calendar year) Not covered You pay first $250 in charges

Remainder of charges (per calendar year) Not covered

After the first $250 in charges, you pay 20% and amounts over $50,000

lifetime max

Policy form numbers: High Deductible Plan F (021193 (06-2010), 021197 (06-2010) Plan G 042193 (01-2018), 042194 (01-2018) Plan N 021191 (06-01-2010), 021195 (06-01-2010)

High Deductible Plan FHigh deductible, lower cost

Plan GOur newest option

Plan NCoverage with a copay

Monthly rates are $5 more if you choose not to enroll in our Automatic Funds Transfer (AFT) program

$89 $185 $170

Your costs: Your costs: Your costs:Any doctor or hospital that

accepts MedicareAny doctor or hospital that

accepts MedicareAny doctor or hospital that

accepts Medicare

$2,240 annual plan deductible Medical - Part B: $183 Medical - Part B: $183

$0 after plan deductible $0 after Part B deductible $20 copay after Part B deductible

$0 after plan deductible $0 after Part B deductible $0

After plan deductible:$0/day (days 1100)All costs (days 101+)

After Part B deductible:$0/day (days 1100)All costs (days 101+)

$0/day (days 1100)All costs (days 101+)

$0 after plan deductible $0 after Part B deductible $0 after Part B deductible$0 after plan deductible $0 after Part B deductible $0 after Part B deductible$0 after plan deductible $0 after Part B deductible $50 copay after Part B deductible$0 after plan deductible $0 after Part B deductible $0 after Part B deductible$0 after plan deductible $0 after Part B deductible $0 after Part B deductible$0 after plan deductible $0 after Part B deductible $0 after Part B deductible

$0 after plan deductible $0 after Part B deductible Not covered

$0 $0 $0$0 $0 $0

Foreign travel coverage (not covered by Medicare)

After plan deductible: You pay first $250 in charges 100% after Part B deductible You pay first $250 in charges

After plan deductible: After the first $250 in charges, you pay 20% and amounts over $50,000 lifetime max

After the first $250 in charges, you pay 20% and amounts over

$50,000 lifetime maximum

After the first $250 in charges, you pay 20% and amounts over

$50,000 lifetime maximum

Which Medicare Supplement plan is right for you?

Our Medicare Supplement plans build on the coverage you get from Parts A and B of Original Medicare, giving you complete coverage. To help you choose the Medicare Supplement plan that best meets your needs

and lifestyle, take a look at this overview that compares each plan we offer and shows you whats covered. You may want to look back at some of your recent medical claims to see what your needs are.

As you consider your options, keep in mind:

Plan A: If you dont need to go to the doctor very often, Plan A is probably a good fit for you.

Plan F: Covers the Part B deductible and excess charges, so this plan could make sense if you are seeking predictability of cost. No surprises!

High deductible F: Designed with cost shares that help you keep monthly premiums low.

Plans F, G, N, and high deductible F: These plans are good choices for anyone who travels abroad a lot, since these plans cover foreign travel emergencies.

Plan G: Looks a lot like our popular Plan F, but youll keep your monthly premiums lower by covering the Part B deductible.

Plan BenefitsPlan A Pays

Plan F Pays

High Deductible F Pays

Plan G Pays

Plan N Pays

Blood (first 3 pints) X X X X X

Foreign travel emergency X X X X

Hospice care coinsurance/copays X X X X X

Parts A and B coinsurance/copays X X X X X

Part A deductible (per benefit period) X X X X

Part B deductible (once a year) X X

Part B excess charges X X X

Skilled nursing facility coinsurance for each day 21100 of benefit period

X X X X

Extra member benefits and services

Customer serviceOur responsive customer service teams are right here in Washington, not thousands of miles away. Were ready to help answer your plan and benefit questions, and were trained and equipped to help get the answers you need, when you need them. Call us at 855-339-4106.

Web toolsOur web tools make it easy for you to see your benefits and costs. Store and manage your health information online, and access health and fitness tracking tools at premera.com.

24-Hour NurseLine**

This free service connects you with registered nurses who answer your medical questions and advise you to get the care you need. Nurses are on call 24 hours a day, 7 days a week. All calls are confidential.

Premera Senior Discounts program**

The Premera Senior Discounts program gives you discounts on things like fitness and weight management programs, eye care and hardware, laser vision correction, contact lenses, and hearing aids.

**These programs are not insurance and may be discontinued at any time.QUESTIONS?

855-339-4106 premera.com

Medicareglossary

Covered servicesthe healthcare services and supplies for which your health plan(s) provides benefits.

Deductiblethe amount you pay for healthcare before Original Medicare begins to pay.

Cost sharesthe amount you pay, such as copays and coinsurance.

Copaythe fixed amount you pay at the time of service for each healthcare visit.

Coinsuranceyour share of the fee for a service. If your plans coinsurance share is 20%, you pay 20% of the allowable charge and your plan pays the other 80% (after you meet your deductible).

Medicare Part A helps pay for inpatient care in hospitals and skilled nursing facilities. Part A is available to most people who are eligible for Medicare at no cost.

Medicare Part B is available for a monthly premium. Medicare Part B helps pay for doctor visits, lab tests, durable medical equipment, and outpatient hospital treatment.

Medicare Part B excess charge is the difference between the Medicare approved amount and is the amount a doctor or other healthcare provider is legally permitted to charge.

Medicare Supplement plans help cover the growing costs Original Medicare alone leaves you to pay.

HERE ARE SOME OTHER DEFINITIONS TO HELP YOU UNDERSTAND MEDICARE AND MEDICARE SUPPLEMENT BENEFITS:

If you dont understand something, just ask us. Its our job to make things easy for you.

Guaranteed acceptanceYou have a six-month window for guaranteed acceptance that begins the month you turn 65 and/or the month your Medicare Part B coverage begins. You must have Medicare Parts A and B to apply for a Medicare Supplement plan. Please contact the plan for other qualifying events that may allow guaranteed acceptance when applying for coverage.

Enrolling is easy! You can:Enroll onlineGo to premera.com

Enroll by mailReturn your paper application to:PO Box 91120, MS295, Seattle, WA 98111-9220

Enroll with your producerSchedule an appointment with your producer for help selecting a plan and submitting your application.

037397 (07-2016)

Discrimination is Against the Law

Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Premera: Provides free aids and services to people with

disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio,

accessible electronic formats, other formats) Provides free language services to people whose

primary language is not English, such as: Qualified interpreters Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Email AppealsDepartmentInquiries@Premera.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Getting Help in Other Languages

This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-722-1471 (TTY: 800-842-5357). (Amharic): Premera Blue Cross 800-722-1471 (TTY: 800-842-5357)

:(Arabic) .

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(Chinese):

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Premera Blue Cross Medicare Supplement plan representatives can help answer your questions.

Call toll free 855-339-4106 (TTY: 711)021138 (01-2018)