outline of medicare supplement coverage — standard ...1 outline of medicare supplement coverage...

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Outline of Medicare Supplement Coverage — Standard Benefits for Plan A and High Deductible Plan F 1 and Standard and Medicare Select 2 Benefits for Plans B, C, F, G, K 3, L 3 and N

This chart shows the benefits included in each of the standard Medicare supplement plans sold for effective dates on or after June 1, 2010. Every company must make Plan “A” available.

Blue Cross and Blue Shield of Illinois does not offer those plans shaded in gray below.

BASIC BENEFITS:• Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.• Medical Expenses – Part B coinsurance (generally 20% of Medicare-approved expenses), or copayments

for hospital outpatient services. Plans K 3, L 3 and N require insureds to pay a portion of Part B coinsurance or copayments.

• Blood – First 3 pints of blood each year.• Hospice – Part A coinsurance.

A Basic Benefits, including 100% Part B Coinsurance

B Basic Benefits, including 100% Part B Coinsurance

Part A Deductible

C Basic Benefits, including 100% Part B Coinsurance

Skilled Nursing Facility

Coinsurance

Part A Deductible

Part B Deductible

Foreign Travel

Emergency

D Basic Benefits, including 100% Part B Coinsurance


Coinsurance

Part A Deductible

Foreign Travel

Emergency

F Basic Benefits, including 100% Part B Coinsurance 1


Coinsurance

Part A Deductible

Part B Deductible

Part B Excess (100%)

Foreign Travel

EmergencyF 1

G Basic Benefits, including 100% Part B Coinsurance


Coinsurance

Part A Deductible

Part B Excess (100%)

Foreign Travel

Emergency

K 3Hospitalization and preventive

care paid at 100%; other basic benefits paid at 50%

50% Skilled Nursing Facility

Coinsurance

50% Part A

Deductible

Out-of-pocket limit 4 $5,560; paid

at 100% after limit reached

L 3Hospitalization and preventive

care paid at 100%; other basic benefits paid at 75%

75% Skilled Nursing Facility

Coinsurance

75% Part A

Deductible

Out-of-pocket limit 4 $2,780; paid

at 100% after limit reached

M Basic Benefits, including 100% Part B Coinsurance


Coinsurance

50% Part A

Deductible

Foreign Travel

Emergency

NBasic Benefits, including

100% Part B coinsurance, except up to $20 copayment

for office visit, and up to $50 copayment for ER


Coinsurance

Part A Deductible

Foreign Travel

Emergency

METCOMOOC 852254.0519 IL

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1 This high deductible plan pays the same benefits as Plan F after one has paid a calendar-year $2,300 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses are $2,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

2 Medicare Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Medicare Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $1,364 deductible is covered at any hospital from which you receive care. Only certain hospitals are network providers under this policy. Check with your physician to determine if he or she has admitting privileges at the network hospital. If he or she does not, you may be required to use another physician at time of hospitalization or you will be required to pay for all expenses. If an insured moves out of the service area, there will be a reduction of benefit coverage and they will have the opportunity to purchase any Medicare Supplement policy with comparable or lesser benefits offered by the insurer, or Medicare Supplement/Select plans A, B, C, F, K, or L from any insurer within 63 days of termination.

3 Plans K and L provide for different cost-sharing for items and services than the other plans we offer. Amounts that count towards the annual limit are noted with an asterisk (*). Once you reach the annual limit, the plan pays 100% of the Medicare copayments and coinsurance for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare approved amounts, called “excess charges.” You will be responsible for paying excess charges.

4 The out-of-pocket annual limit will increase each year for inflation.

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Monthly Premium Rates effective May 1, 2019Rates shown are for Illinois residents living in Cook, DuPage, Kane, Lake, McHenry or Will Counties only.

If you’re an Illinois resident living outside of Cook, DuPage, Kane, Lake, McHenry or Will County, please call the toll-free number that appears on the application and throughout the information packet.

Age 65 FEMALE MALE

Standard Med-Select 2 Standard Med-Select 2

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

A $103.06 $93.69 N / A N / A $117.46 $106.78 N / A N / A

B $135.53 $123.21 $120.62 $109.66 $154.46 $140.42 $137.47 $124.98

C $165.74 $150.67 $147.51 $134.10 $188.90 $171.72 $168.12 $152.83

F $166.24 $151.13 $147.95 $134.50 $189.46 $172.24 $168.62 $153.29

High F 1 $48.37 $43.97 N / A N / A $55.13 $50.12 N / A N / A

G $140.63 $127.85 $125.16 $113.78 $162.70 $147.90 $144.80 $131.64

K 3 $81.34 $73.95 $76.87 $69.88 $92.70 $84.28 $87.61 $79.64

L 3 $114.27 $103.88 $104.84 $95.31 $130.23 $118.39 $119.49 $108.63

N $114.67 $104.25 $102.06 $92.78 $132.66 $120.60 $118.07 $107.34

Age 66 FEMALE MALE



A $109.44 $99.49 N / A N / A $124.73 $113.39 N / A N / A

B $143.91 $130.83 $128.08 $116.44 $164.02 $149.11 $145.98 $132.71

C $176.00 $160.00 $156.64 $142.40 $200.58 $182.35 $178.52 $162.29

F $176.53 $160.48 $157.11 $142.82 $201.19 $182.90 $179.06 $162.78

High F 1 $51.36 $46.69 N / A N / A $58.54 $53.22 N / A N / A

G $150.40 $136.73 $133.86 $121.69 $173.83 $158.03 $154.71 $140.64

K 3 $86.37 $78.52 $81.62 $74.20 $98.44 $89.49 $93.02 $84.57

L 3 $121.34 $110.31 $111.33 $101.21 $138.29 $125.72 $126.88 $115.35

N $122.64 $111.49 $109.15 $99.23 $141.74 $128.86 $126.15 $114.68

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Age 67 FEMALE MALE



A $115.70 $105.18 N / A N / A $131.86 $119.88 N / A N / A

B $152.15 $138.32 $135.41 $123.10 $173.41 $157.64 $154.33 $140.30

C $186.07 $169.15 $165.60 $150.54 $212.06 $192.78 $188.73 $171.58

F $186.63 $169.66 $166.10 $151.00 $212.70 $193.36 $189.30 $172.09

High F 1 $54.30 $49.37 N / A N / A $61.89 $56.26 N / A N / A

G $160.00 $145.45 $142.40 $129.45 $184.77 $167.97 $164.44 $149.49

K 3 $91.31 $83.01 $86.29 $78.45 $104.07 $94.61 $98.35 $89.41

L 3 $128.28 $116.62 $117.70 $107.00 $146.20 $132.91 $134.14 $121.95

N $130.46 $118.60 $116.11 $105.56 $150.66 $136.96 $134.09 $121.90

Age 68 FEMALE MALE



A $121.85 $110.77 N / A N / A $138.87 $126.25 N / A N / A

B $160.23 $145.67 $142.61 $129.64 $182.62 $166.02 $162.53 $147.76

C $195.95 $178.14 $174.40 $158.54 $223.33 $203.03 $198.76 $180.69

F $196.54 $178.68 $174.92 $159.02 $224.00 $203.64 $199.36 $181.24

High F 1 $57.19 $51.99 N / A N / A $65.18 $59.25 N / A N / A

G $169.42 $154.02 $150.78 $137.08 $195.50 $177.73 $174.00 $158.18

K 3 $96.17 $87.42 $90.88 $82.62 $109.60 $99.64 $103.57 $94.16

L 3 $135.10 $122.82 $123.95 $112.68 $153.97 $139.97 $141.27 $128.43

N $138.15 $125.59 $122.95 $111.77 $159.42 $144.92 $141.88 $128.98

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Age 69 FEMALE MALE



A $127.88 $116.26 N / A N / A $145.75 $132.50 N / A N / A

B $168.17 $152.88 $149.67 $136.06 $191.66 $174.24 $170.58 $155.07

C $205.66 $186.96 $183.03 $166.39 $234.39 $213.08 $208.60 $189.64

F $206.28 $187.52 $183.59 $166.90 $235.09 $213.72 $209.23 $190.21

High F 1 $60.02 $54.56 N / A N / A $68.41 $62.19 N / A N / A

G $178.67 $162.42 $159.01 $144.56 $206.04 $187.31 $183.38 $166.71

K 3 $100.93 $91.75 $95.38 $86.71 $115.03 $104.57 $108.70 $98.82

L 3 $141.79 $128.90 $130.09 $118.26 $161.60 $146.91 $148.26 $134.79

N $145.69 $132.44 $129.66 $117.87 $168.01 $152.73 $149.53 $135.93

Age 70 FEMALE MALE



A $133.80 $121.64 N / A N / A $152.50 $138.63 N / A N / A

B $175.95 $159.96 $156.60 $142.36 $200.54 $182.31 $178.48 $162.25

C $215.18 $195.62 $191.51 $174.10 $245.24 $222.94 $218.26 $198.42

F $215.83 $196.20 $192.08 $174.62 $245.98 $223.62 $218.92 $199.02

High F 1 $62.80 $57.09 N / A N / A $71.57 $65.07 N / A N / A

G $187.74 $170.67 $167.09 $151.90 $216.38 $196.71 $192.58 $175.07

K 3 $105.60 $96.00 $99.79 $90.72 $120.35 $109.41 $113.73 $103.40

L 3 $148.35 $134.87 $136.11 $123.74 $169.08 $153.71 $155.13 $141.03

N $153.08 $139.17 $136.24 $123.86 $176.44 $160.40 $157.03 $142.76

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Age 71 FEMALE MALE



A $139.61 $126.92 N / A N / A $159.11 $144.65 N / A N / A

B $183.59 $166.90 $163.40 $148.54 $209.24 $190.22 $186.22 $169.29

C $224.52 $204.10 $199.82 $181.65 $255.88 $232.62 $227.73 $207.03

F $225.19 $204.72 $200.42 $182.20 $256.65 $233.32 $228.42 $207.65

High F 1 $65.52 $59.57 N / A N / A $74.68 $67.89 N / A N / A

G $196.63 $178.76 $175.01 $159.10 $226.52 $205.93 $201.60 $183.28

K 3 $110.18 $100.17 $104.12 $94.66 $125.58 $114.16 $118.67 $107.88

L 3 $154.79 $140.72 $142.02 $129.11 $176.41 $160.38 $161.86 $147.15

N $160.34 $145.76 $142.70 $129.73 $184.71 $167.92 $164.39 $149.45

Age 72 FEMALE MALE



A $145.30 $132.09 N / A N / A $165.60 $150.55 N / A N / A

B $191.08 $173.71 $170.06 $154.60 $217.77 $197.97 $193.82 $176.20

C $233.67 $212.43 $207.97 $189.06 $266.31 $242.10 $237.02 $215.47

F $234.37 $213.07 $208.59 $189.63 $267.12 $242.83 $237.73 $216.12

High F 1 $68.20 $62.00 N / A N / A $77.72 $70.66 N / A N / A

G $205.36 $186.69 $182.77 $166.15 $236.46 $214.97 $210.45 $191.32

K 3 $114.68 $104.25 $108.37 $98.52 $130.70 $118.82 $123.51 $112.28

L 3 $161.10 $146.46 $147.81 $134.37 $183.61 $166.92 $168.46 $153.15

N $167.45 $152.23 $149.03 $135.48 $192.81 $175.29 $171.60 $156.00

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Age 73 FEMALE MALE



A $150.88 $137.16 N / A N / A $171.96 $156.33 N / A N / A

B $198.41 $180.37 $176.59 $160.53 $226.13 $205.57 $201.26 $182.96

C $242.64 $220.58 $215.95 $196.32 $276.54 $251.40 $246.12 $223.74

F $243.37 $221.25 $216.60 $196.91 $277.37 $252.16 $246.86 $224.42

High F 1 $70.81 $64.38 N / A N / A $80.71 $73.37 N / A N / A

G $213.91 $194.46 $190.38 $173.07 $246.21 $223.82 $219.12 $199.20

K 3 $119.08 $108.25 $112.53 $102.30 $135.72 $123.38 $128.25 $116.59

L 3 $167.29 $152.08 $153.49 $139.53 $190.66 $173.32 $174.93 $159.02

N $174.42 $158.56 $155.23 $141.12 $200.76 $182.51 $178.67 $162.43

Age 74 FEMALE MALE



A $156.34 $142.13 N / A N / A $178.19 $161.99 N / A N / A

B $205.60 $186.91 $182.98 $166.35 $234.32 $213.02 $208.55 $189.59

C $251.43 $228.57 $223.77 $203.43 $286.55 $260.50 $255.03 $231.85

F $252.19 $229.26 $224.45 $204.04 $287.42 $261.29 $255.80 $232.55

High F 1 $73.38 $66.71 N / A N / A $83.63 $76.03 N / A N / A

G $222.28 $202.07 $197.83 $179.84 $255.75 $232.50 $227.62 $206.92

K 3 $123.39 $112.18 $116.61 $106.01 $140.63 $127.85 $132.90 $120.81

L 3 $173.35 $157.59 $159.04 $144.59 $197.56 $179.60 $181.26 $164.78

N $181.25 $164.77 $161.31 $146.65 $208.54 $189.58 $185.60 $168.73

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Age 75 FEMALE MALE



A $161.70 $147.00 N / A N / A $184.28 $167.53 N / A N / A

B $212.63 $193.30 $189.24 $172.04 $242.34 $220.31 $215.68 $196.08

C $260.03 $236.39 $231.43 $210.39 $296.36 $269.42 $263.76 $239.78

F $260.82 $237.11 $232.13 $211.02 $297.25 $270.23 $264.56 $240.50

High F 1 $75.89 $68.99 N / A N / A $86.49 $78.63 N / A N / A

G $230.48 $209.53 $205.13 $186.48 $265.09 $240.99 $235.93 $214.49

K 3 $127.62 $116.01 $120.60 $109.63 $145.44 $132.22 $137.44 $124.95

L 3 $179.28 $162.98 $164.49 $149.53 $204.32 $185.75 $187.47 $170.42

N $187.93 $170.85 $167.26 $152.06 $216.16 $196.51 $192.38 $174.89

Age 76 FEMALE MALE



A $166.93 $151.76 N / A N / A $190.25 $172.96 N / A N / A

B $219.52 $199.56 $195.37 $177.61 $250.19 $227.44 $222.67 $202.43

C $268.46 $244.05 $238.93 $217.20 $305.96 $278.14 $272.30 $247.55

F $269.26 $244.79 $239.64 $217.86 $306.88 $278.98 $273.12 $248.29

High F 1 $78.35 $71.23 N / A N / A $89.29 $81.18 N / A N / A

G $238.50 $216.82 $212.27 $192.97 $274.24 $249.31 $244.07 $221.88

K 3 $131.75 $119.77 $124.50 $113.18 $150.15 $136.50 $141.90 $129.00

L 3 $185.08 $168.26 $169.81 $154.38 $210.94 $191.76 $193.54 $175.94

N $194.48 $176.80 $173.09 $157.35 $223.62 $203.29 $199.02 $180.93

9

Age 77 FEMALE MALE



A $172.05 $156.41 N / A N / A $196.09 $178.26 N / A N / A

B $226.26 $205.69 $201.37 $183.06 $257.87 $234.42 $229.50 $208.64

C $276.69 $251.54 $246.26 $223.87 $315.35 $286.68 $280.66 $255.15

F $277.53 $252.30 $247.00 $224.54 $316.30 $287.54 $281.51 $255.91

High F 1 $80.75 $73.41 N / A N / A $92.03 $83.67 N / A N / A

G $246.35 $223.96 $219.25 $199.32 $283.19 $257.44 $252.04 $229.12

K 3 $135.79 $123.45 $128.32 $116.66 $154.76 $140.69 $146.25 $132.95

L 3 $190.76 $173.42 $175.03 $159.11 $217.41 $197.65 $199.48 $181.34

N $200.88 $182.62 $178.78 $162.53 $230.91 $209.92 $205.51 $186.83

Age 78 FEMALE MALE



A $177.06 $160.97 N / A N / A $201.80 $183.45 N / A N / A

B $232.84 $211.68 $207.23 $188.39 $265.37 $241.25 $236.18 $214.71

C $284.75 $258.86 $253.43 $230.39 $324.53 $295.03 $288.83 $262.57

F $285.61 $259.64 $254.19 $231.08 $325.51 $295.91 $289.70 $263.36

High F 1 $83.10 $75.55 N / A N / A $94.71 $86.10 N / A N / A

G $254.03 $230.94 $226.09 $205.53 $291.93 $265.39 $259.82 $236.20

K 3 $139.75 $127.04 $132.06 $120.05 $159.27 $144.79 $150.51 $136.83

L 3 $196.32 $178.47 $180.12 $163.75 $223.74 $203.40 $205.28 $186.62

N $207.14 $188.31 $184.35 $167.59 $238.05 $216.41 $211.86 $192.60

10

Age 79 FEMALE MALE



A $181.96 $165.42 N / A N / A $207.38 $188.53 N / A N / A

B $239.28 $217.53 $212.96 $193.60 $272.71 $247.92 $242.71 $220.65

C $292.62 $266.02 $260.43 $236.76 $333.50 $303.18 $296.82 $269.83

F $293.50 $266.82 $261.22 $237.47 $334.51 $304.10 $297.71 $270.65

High F 1 $85.40 $77.64 N / A N / A $97.33 $88.48 N / A N / A

G $261.53 $237.75 $232.76 $211.60 $300.48 $273.17 $267.43 $243.12

K 3 $143.61 $130.55 $135.71 $123.37 $163.67 $148.79 $154.67 $140.61

L 3 $201.74 $183.40 $185.10 $168.27 $229.93 $209.03 $210.96 $191.78

N $213.25 $193.87 $189.80 $172.54 $245.02 $222.74 $218.06 $198.24

Age 80 FEMALE MALE



A $186.74 $169.76 N / A N / A $212.83 $193.48 N / A N / A

B $245.57 $223.24 $218.56 $198.69 $279.88 $254.43 $249.09 $226.45

C $300.31 $273.01 $267.28 $242.98 $342.26 $311.15 $304.61 $276.92

F $301.21 $273.83 $268.08 $243.71 $343.29 $312.09 $305.53 $277.76

High F 1 $87.64 $79.68 N / A N / A $99.89 $90.81 N / A N / A

G $268.86 $244.42 $239.28 $217.53 $308.83 $280.76 $274.86 $249.87

K 3 $147.38 $133.98 $139.28 $126.61 $167.97 $152.70 $158.73 $144.30

L 3 $207.05 $188.22 $189.96 $172.70 $235.97 $214.52 $216.50 $196.82

N $219.23 $199.30 $195.11 $177.38 $251.83 $228.93 $224.12 $203.75

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Age 81 FEMALE MALE



A $191.41 $174.01 N / A N / A $218.15 $198.32 N / A N / A

B $251.71 $228.82 $224.02 $203.65 $286.87 $260.79 $255.32 $232.10

C $307.82 $279.83 $273.96 $249.05 $350.82 $318.93 $312.23 $283.84

F $308.74 $280.68 $274.78 $249.80 $351.87 $319.89 $313.17 $284.70

High F 1 $89.83 $81.67 N / A N / A $102.38 $93.08 N / A N / A

G $276.01 $250.92 $245.65 $223.32 $316.98 $288.17 $282.12 $256.47

K 3 $151.07 $137.33 $142.76 $129.78 $172.17 $156.52 $162.70 $147.91

L 3 $212.22 $192.93 $194.71 $177.01 $241.87 $219.88 $221.91 $201.74

N $225.06 $204.60 $200.30 $182.09 $258.47 $234.97 $230.04 $209.13

Age 82 FEMALE MALE



A $195.96 $178.15 N / A N / A $223.34 $203.03 N / A N / A

B $257.69 $234.27 $229.35 $208.50 $293.70 $267.00 $261.39 $237.63

C $315.14 $286.49 $280.47 $254.98 $359.16 $326.51 $319.66 $290.60

F $316.09 $287.35 $281.32 $255.74 $360.25 $327.50 $320.62 $291.47

High F 1 $91.97 $83.61 N / A N / A $104.82 $95.29 N / A N / A

G $282.99 $257.26 $251.86 $228.96 $324.94 $295.40 $289.19 $262.90

K 3 $154.66 $140.60 $146.15 $132.87 $176.27 $160.24 $166.57 $151.43

L 3 $217.27 $197.52 $199.34 $181.22 $247.62 $225.11 $227.19 $206.54

N $230.75 $209.77 $205.37 $186.70 $264.96 $240.87 $235.81 $214.37

12

Age 83 FEMALE MALE



A $200.40 $182.18 N / A N / A $228.40 $207.63 N / A N / A

B $263.53 $239.58 $234.54 $213.22 $300.35 $273.04 $267.31 $243.01

C $322.28 $292.98 $286.83 $260.75 $367.30 $333.91 $326.90 $297.18

F $323.25 $293.86 $287.69 $261.54 $368.41 $334.91 $327.88 $298.07

High F 1 $94.06 $85.50 N / A N / A $107.20 $97.45 N / A N / A

G $289.79 $263.44 $257.91 $234.47 $332.69 $302.44 $296.09 $269.18

K 3 $158.16 $143.78 $149.46 $135.88 $180.26 $163.87 $170.34 $154.86

L 3 $222.19 $201.99 $203.86 $185.33 $253.23 $230.21 $232.34 $211.22

N $236.30 $214.81 $210.30 $191.19 $271.28 $246.62 $241.44 $219.49

Age 84 FEMALE MALE



A $204.73 $186.11 N / A N / A $233.33 $212.11 N / A N / A

B $269.22 $244.75 $239.61 $217.82 $306.83 $278.94 $273.08 $248.25

C $329.23 $299.30 $293.02 $266.38 $375.23 $341.12 $333.95 $303.59

F $330.23 $300.20 $293.90 $267.18 $376.36 $342.14 $334.96 $304.51

High F 1 $96.09 $87.35 N / A N / A $109.51 $99.55 N / A N / A

G $296.42 $269.47 $263.81 $239.83 $340.24 $309.31 $302.82 $275.29

K 3 $161.58 $146.89 $152.69 $138.81 $184.15 $167.41 $174.02 $158.20

L 3 $226.99 $206.35 $208.26 $189.33 $258.70 $235.18 $237.36 $215.78

N $241.70 $219.73 $215.11 $195.56 $277.44 $252.22 $246.92 $224.47

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Age 85 FEMALE MALE



A $208.94 $189.94 N / A N / A $238.13 $216.48 N / A N / A

B $274.76 $249.78 $244.54 $222.31 $313.14 $284.68 $278.70 $253.36

C $336.01 $305.46 $299.05 $271.86 $382.95 $348.13 $340.82 $309.84

F $337.02 $306.38 $299.95 $272.68 $384.10 $349.18 $341.85 $310.77

High F 1 $98.06 $89.15 N / A N / A $111.76 $101.60 N / A N / A

G $302.87 $275.34 $269.56 $245.05 $347.60 $316.00 $309.36 $281.24

K 3 $164.90 $149.91 $155.83 $141.66 $187.94 $170.85 $177.60 $161.46

L 3 $231.66 $210.60 $212.55 $193.22 $264.02 $240.02 $242.24 $220.22

N $246.96 $224.51 $219.80 $199.82 $283.44 $257.67 $252.26 $229.32

Age 86 FEMALE MALE



A $213.03 $193.67 N / A N / A $242.80 $220.72 N / A N / A

B $280.15 $254.68 $249.33 $226.67 $319.29 $290.26 $284.16 $258.33

C $342.60 $311.45 $304.91 $277.19 $390.46 $354.96 $347.51 $315.92

F $343.63 $312.39 $305.83 $278.03 $391.63 $356.03 $348.55 $316.87

High F 1 $99.99 $90.90 N / A N / A $113.95 $103.59 N / A N / A

G $309.15 $281.05 $275.14 $250.13 $354.76 $322.50 $315.73 $287.03

K 3 $168.13 $152.85 $158.89 $144.44 $191.62 $174.20 $181.08 $164.62

L 3 $236.20 $214.73 $216.71 $197.01 $269.20 $244.73 $246.99 $224.54

N $252.08 $229.17 $224.35 $203.96 $289.27 $262.97 $257.45 $234.05

14

Age 87 FEMALE MALE



A $217.02 $197.29 N / A N / A $247.34 $224.85 N / A N / A

B $285.39 $259.44 $253.99 $230.90 $325.26 $295.69 $289.48 $263.16

C $349.00 $317.28 $310.61 $282.38 $397.76 $361.60 $354.01 $321.82

F $350.05 $318.23 $311.55 $283.23 $398.96 $362.69 $355.07 $322.79

High F 1 $101.86 $92.60 N / A N / A $116.08 $105.53 N / A N / A

G $315.25 $286.60 $280.58 $255.07 $361.71 $328.83 $321.92 $292.66

K 3 $171.28 $155.71 $161.86 $147.14 $195.21 $177.46 $184.47 $167.70

L 3 $240.62 $218.74 $220.77 $200.70 $274.23 $249.30 $251.61 $228.73

N $257.06 $233.69 $228.78 $207.99 $294.94 $268.13 $262.50 $238.64

Age 88 FEMALE MALE



A $220.89 $200.81 N / A N / A $251.75 $228.86 N / A N / A

B $290.48 $264.07 $258.52 $235.02 $331.06 $300.96 $294.64 $267.85

C $355.23 $322.93 $316.15 $287.41 $404.85 $368.05 $360.32 $327.56

F $356.30 $323.91 $317.10 $288.28 $406.07 $369.16 $361.40 $328.55

High F 1 $103.67 $94.25 N / A N / A $118.15 $107.41 N / A N / A

G $321.18 $291.99 $285.85 $259.87 $368.47 $334.97 $327.94 $298.13

K 3 $174.33 $158.48 $164.74 $149.77 $198.69 $180.63 $187.76 $170.69

L 3 $244.91 $222.64 $224.70 $204.28 $279.12 $253.75 $256.09 $232.81

N $261.90 $238.09 $233.09 $211.90 $300.45 $273.14 $267.40 $243.10

15

Age 89 FEMALE MALE



A $224.64 $204.22 N / A N / A $256.03 $232.75 N / A N / A

B $295.41 $268.56 $262.92 $239.02 $336.68 $306.08 $299.65 $272.41

C $361.27 $328.42 $321.53 $292.30 $411.74 $374.31 $366.45 $333.13

F $362.35 $329.41 $322.50 $293.18 $412.98 $375.43 $367.55 $334.14

High F 1 $105.43 $95.85 N / A N / A $120.16 $109.24 N / A N / A

G $326.94 $297.22 $290.98 $264.52 $375.03 $340.94 $333.78 $303.43

K 3 $177.30 $161.18 $167.55 $152.31 $202.07 $183.70 $190.95 $173.59

L 3 $249.07 $226.43 $228.52 $207.75 $283.87 $258.06 $260.45 $236.77

N $266.59 $242.35 $237.26 $215.70 $305.80 $278.00 $272.16 $247.42

Age 90 FEMALE MALE



A $228.29 $207.53 N / A N / A $260.18 $236.53 N / A N / A

B $300.20 $272.91 $267.18 $242.89 $342.14 $311.04 $304.51 $276.83

C $367.12 $333.75 $326.74 $297.04 $418.41 $380.37 $372.39 $338.53

F $368.23 $334.75 $327.72 $297.93 $419.67 $381.52 $373.51 $339.55

High F 1 $107.14 $97.40 N / A N / A $122.11 $111.01 N / A N / A

G $332.52 $302.29 $295.94 $269.04 $381.39 $346.72 $339.44 $308.58

K 3 $180.17 $163.79 $170.26 $154.78 $205.34 $186.67 $194.05 $176.41

L 3 $253.11 $230.10 $232.23 $211.12 $288.47 $262.25 $264.67 $240.61

N $271.14 $246.49 $241.32 $219.38 $310.99 $282.72 $276.78 $251.62

16

Age 91 FEMALE MALE



A $231.81 $210.74 N / A N / A $264.20 $240.18 N / A N / A

B $304.84 $277.13 $271.31 $246.65 $347.43 $315.85 $309.21 $281.10

C $372.80 $338.91 $331.79 $301.63 $424.88 $386.25 $378.14 $343.77

F $373.92 $339.93 $332.79 $302.54 $426.16 $387.42 $379.28 $344.80

High F 1 $108.80 $98.91 N / A N / A $124.00 $112.73 N / A N / A

G $337.93 $307.21 $300.76 $273.41 $387.55 $352.32 $344.92 $313.57

K 3 $182.96 $166.32 $172.89 $157.18 $208.52 $189.56 $197.05 $179.13

L 3 $257.02 $233.66 $235.82 $214.38 $292.93 $266.30 $268.76 $244.33

N $275.55 $250.50 $245.24 $222.94 $316.01 $287.29 $281.25 $255.68

Age 92 FEMALE MALE



A $235.23 $213.84 N / A N / A $268.09 $243.72 N / A N / A

B $309.33 $281.21 $275.31 $250.28 $352.55 $320.50 $313.77 $285.24

C $378.29 $343.90 $336.68 $306.07 $431.14 $391.94 $383.71 $348.83

F $379.43 $344.93 $337.69 $306.99 $432.43 $393.12 $384.87 $349.88

High F 1 $110.40 $100.37 N / A N / A $125.83 $114.39 N / A N / A

G $343.16 $311.96 $305.41 $277.65 $393.52 $357.74 $350.23 $318.39

K 3 $185.65 $168.77 $175.44 $159.49 $211.59 $192.35 $199.95 $181.77

L 3 $260.81 $237.10 $239.29 $217.54 $297.24 $270.22 $272.72 $247.93

N $279.82 $254.38 $249.04 $226.40 $320.88 $291.71 $285.58 $259.62

17

Age 93 FEMALE MALE



A $238.53 $216.84 N / A N / A $271.85 $247.14 N / A N / A

B $313.67 $285.16 $279.17 $253.79 $357.49 $325.00 $318.17 $289.25

C $383.60 $348.72 $341.40 $310.36 $437.18 $397.44 $389.09 $353.72

F $384.75 $349.77 $342.43 $311.30 $438.50 $398.64 $390.27 $354.79

High F 1 $111.95 $101.77 N / A N / A $127.59 $115.99 N / A N / A

G $348.22 $316.56 $309.91 $281.74 $399.28 $362.98 $355.36 $323.05

K 3 $188.26 $171.14 $177.90 $161.73 $214.56 $195.05 $202.75 $184.32

L 3 $264.47 $240.42 $242.65 $220.59 $301.41 $274.01 $276.55 $251.41

N $283.94 $258.13 $252.71 $229.73 $325.58 $295.98 $289.76 $263.42

Age 94 FEMALE MALE



A $241.72 $219.74 N / A N / A $275.48 $250.44 N / A N / A

B $317.86 $288.97 $282.90 $257.18 $362.27 $329.34 $322.42 $293.11

C $388.72 $353.38 $345.96 $314.51 $443.02 $402.75 $394.29 $358.45

F $389.89 $354.45 $347.00 $315.46 $444.36 $403.96 $395.48 $359.53

High F 1 $113.45 $103.13 N / A N / A $129.30 $117.54 N / A N / A

G $353.10 $321.00 $314.26 $285.69 $404.84 $368.04 $360.31 $327.56

K 3 $190.77 $173.43 $180.28 $163.89 $217.42 $197.66 $205.46 $186.78

L 3 $268.00 $243.64 $245.89 $223.54 $305.44 $277.67 $280.24 $254.76

N $287.92 $261.75 $256.25 $232.95 $330.11 $300.10 $293.80 $267.09

18

Age 95 FEMALE MALE



A $244.79 $222.53 N / A N / A $278.99 $253.62 N / A N / A

B $321.90 $292.64 $286.49 $260.45 $366.88 $333.52 $326.52 $296.84

C $393.66 $357.87 $350.36 $318.51 $448.66 $407.87 $399.30 $363.00

F $394.85 $358.95 $351.41 $319.47 $450.01 $409.10 $400.51 $364.10

High F 1 $114.89 $104.44 N / A N / A $130.94 $119.04 N / A N / A

G $357.81 $325.28 $318.45 $289.50 $410.21 $372.92 $365.09 $331.90

K 3 $193.20 $175.63 $182.57 $165.97 $220.19 $200.17 $208.07 $189.16

L 3 $271.41 $246.73 $249.01 $226.38 $309.32 $281.20 $283.80 $258.00

N $291.76 $265.24 $259.67 $236.06 $334.49 $304.08 $297.70 $270.63

Age 96 FEMALE MALE



A $247.75 $225.22 N / A N / A $282.36 $256.69 N / A N / A

B $325.79 $296.18 $289.96 $263.60 $371.31 $337.55 $330.47 $300.42

C $398.42 $362.20 $354.59 $322.36 $454.08 $412.80 $404.13 $367.39

F $399.62 $363.29 $355.66 $323.33 $455.45 $414.04 $405.35 $368.50

High F 1 $116.28 $105.71 N / A N / A $132.52 $120.47 N / A N / A

G $362.34 $329.40 $322.48 $293.17 $415.38 $377.62 $369.69 $336.08

K 3 $195.53 $177.75 $184.78 $167.98 $222.85 $202.59 $210.59 $191.45

L 3 $274.69 $249.71 $252.02 $229.11 $313.06 $284.60 $287.23 $261.12

N $295.46 $268.60 $262.96 $239.05 $338.70 $307.91 $301.45 $274.04

19

Age 97 FEMALE MALE



A $250.59 $227.81 N / A N / A $285.60 $259.64 N / A N / A

B $329.54 $299.58 $293.29 $266.62 $375.57 $341.43 $334.26 $303.87

C $402.99 $366.36 $358.66 $326.06 $459.29 $417.54 $408.77 $371.61

F $404.21 $367.46 $359.74 $327.04 $460.68 $418.80 $410.00 $372.73

High F 1 $117.61 $106.92 N / A N / A $134.04 $121.86 N / A N / A

G $366.70 $333.36 $326.36 $296.69 $420.35 $382.13 $374.11 $340.10

K 3 $197.78 $179.80 $186.90 $169.91 $225.41 $204.91 $213.01 $193.64

L 3 $277.84 $252.58 $254.92 $231.74 $316.66 $287.87 $290.53 $264.12

N $299.01 $271.83 $266.12 $241.93 $342.75 $311.59 $305.05 $277.32

Age 98 FEMALE MALE



A $253.32 $230.29 N / A N / A $288.71 $262.47 N / A N / A

B $333.13 $302.84 $296.48 $269.53 $379.67 $345.15 $337.90 $307.18

C $407.39 $370.35 $362.57 $329.61 $464.30 $422.09 $413.23 $375.66

F $408.61 $371.47 $363.66 $330.60 $465.70 $423.36 $414.47 $376.79

High F 1 $118.89 $108.09 N / A N / A $135.50 $123.19 N / A N / A

G $370.88 $337.17 $330.09 $300.08 $425.11 $386.47 $378.35 $343.96

K 3 $199.93 $181.76 $188.93 $171.76 $227.86 $207.15 $215.33 $195.75

L 3 $280.87 $255.33 $257.70 $234.27 $320.11 $291.01 $293.70 $267.00

N $302.42 $274.93 $269.16 $244.69 $346.64 $315.13 $308.51 $280.46

20

Age 99 FEMALE MALE



A $255.94 $232.67 N / A N / A $291.69 $265.18 N / A N / A

B $336.57 $305.97 $299.55 $272.31 $383.59 $348.72 $341.39 $310.36

C $411.59 $374.18 $366.32 $333.02 $469.09 $426.45 $417.49 $379.54

F $412.83 $375.30 $367.42 $334.02 $470.51 $427.73 $418.75 $380.68

High F 1 $120.12 $109.20 N / A N / A $136.90 $124.46 N / A N / A

G $374.89 $340.81 $333.66 $303.32 $429.68 $390.62 $382.42 $347.65

K 3 $202.00 $183.63 $190.89 $173.53 $230.22 $209.29 $217.55 $197.78

L 3 $283.77 $257.97 $260.36 $236.69 $323.41 $294.01 $296.73 $269.76

N $305.69 $277.90 $272.07 $247.33 $350.37 $318.52 $311.83 $283.48

Age 100 + FEMALE MALE



A $258.44 $234.95 N / A N / A $294.55 $267.77 N / A N / A

B $339.86 $308.96 $302.48 $274.98 $387.34 $352.13 $344.73 $313.39

C $415.62 $377.84 $369.90 $336.27 $473.68 $430.62 $421.58 $383.25

F $416.87 $378.97 $371.01 $337.29 $475.11 $431.92 $422.85 $384.41

High F 1 $121.30 $110.27 N / A N / A $138.24 $125.67 N / A N / A

G $378.73 $344.30 $337.07 $306.43 $434.06 $394.60 $386.31 $351.19

K 3 $203.97 $185.43 $192.75 $175.23 $232.47 $211.33 $219.68 $199.71

L 3 $286.54 $260.49 $262.90 $239.00 $326.58 $296.89 $299.63 $272.39

N $308.82 $280.75 $274.85 $249.86 $353.93 $321.76 $315.00 $286.36

21

You have the option to purchase any of the Medicare Supplement benefit plans shown on the front cover in white as Standard Plans or as Medicare Select Plans, with the exception of Plan A and High Deductible Plan F 1, which are available as Standard Plans only.

Medicare Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Medicare Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $1,364 deductible is covered at any hospital from which you receive care. Only certain hospitals are network providers under this policy. Check with your physician to determine if he or she has admitting privileges at the network hospital. If he or she does not, you may be required to use another physician at time of hospitalization or you will be required to pay for all expenses. If you move out of the service area, there will be a reduction of benefit coverage and you will have the opportunity to purchase any Medicare Supplement policy with comparable or lesser benefits offered by the insurer, or Medicare Supplement/Select plans A, B, C, F, K, or L from any insurer within 63 days of termination.

PREMIUM INFORMATIONBlue Cross and Blue Shield of Illinois can only raise your premium if we raise the premium for all policies like yours in the state. We will not change your premium or cancel your policy because of poor health. Premiums change at age 65 and every year thereafter up to age 100. If your premium changes, you will be notified at least 30 days in advance.

Gender

One factor that will determine your premium is your gender. When completing the application, you will need to make a gender selection.

Household Discount

You may be eligible for a household discount if at least two household members reside in the same household and are enrolled in a BCBSIL Medicare Supplement Insurance Plan effective on or after May 1, 2019.

Tobacco User

A Tobacco User is a person who is permitted under state and federal law to legally use Tobacco, with Tobacco use (other than religious or ceremonial use of Tobacco) occurring on average of four or more times per week that last occurred within the past six months. Tobacco products include but are not limited to: cigarettes, cigars, smokeless tobacco products, electronic cigarettes, dissolvable tobacco products, and vaping.

If you meet the definition of a Tobacco User, you may pay a higher premium for your health coverage.

22

DISCLOSURESUse this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLYThis 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 YOUR POLICYIf you find that you are not satisfied with your policy, you may return it to Blue Medicare Supplement c/o Member Services, P.O. Box 3388 Scranton, PA 18505. 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 will return all of your payments.

POLICY REPLACEMENTIf 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.

NOTICEThis policy may not fully cover all of your medical costs. Neither Blue Cross and Blue Shield of Illinois nor its agents are connected with Medicare. This Outline of Coverage does not give you all the details of Medicare coverage. Contact your local Social Security Office or consult “Medicare & You” for more details.

COMPLETE ANSWERS ARE VERY IMPORTANTReview the application carefully before you sign it. Be certain that all information has been properly recorded.

MEDICARE SELECT ADDITIONAL DISCLOSURES

GRIEVANCE PROCEDURESOur goal is your 100% satisfaction with our processing of your coverage. Should you ever not be fully satisfied with any aspect of the services you receive, we want to know about it so we can correct it.

If you have any dissatisfaction with your Medicare Select coverage, please send all written grievances within 60 days of the occurrence of your dissatisfaction to: Medicare Supplement Grievance Committee, P.O. Box 3004, Naperville, IL 60566-9747 or fax (888) 235-2949.

Your grievance will be reviewed by our Grievance Committee. Upon review of your grievance, we will mail you a response within 30 days from the receipt of your written correspondence. If additional information from an outside source is required, we may require an additional 30 days to research, finalize and respond to your correspondence. In no case will a complete response from us take more than 60 days.

If you are dissatisfied with the decision of our Grievance Committee you may submit a written complaint to the Illinois Insurance Department, 320 Washington Street, 4th Floor, Springfield, Illinois 62766 or call (217) 782-4515.

QUALITY ASSURANCEAs part of our Quality Assurance program, all contracted hospitals must meet Medicare standards.

In addition, hospitals must meet the contract criteria stated in the Hospital Agreement.

Each hospital must: agree to maintain its state licensure; agree to maintain its Blue Cross and Blue Shield of Illinois Plan Hospital status; agree to maintain its Medicare participating status; be accredited and maintain its accreditation by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic Association (AOA); and agree to waive the Part A deductible.

MEDICARE SELECT HOSPITAL RESTRICTIONSPlans B, C, F, G, K, L and N are Medicare Select policies currently available if you live within 30 miles of a Medicare Select hospital. Part A benefits may be restricted if you receive services in a hospital that is not a Medicare Select Hospital.

The full benefits of your coverage, excluding Plan K & L coinsurance, will be paid anywhere if:1. Services are provided in a Doctor’s office, another

office setting, or in a skilled nursing facility;2. The services are for symptoms requiring emergency

care or are immediately required for an unforeseen illness, injury or condition and it is not reasonable to obtain such services from a Medicare Select Hospital (such as while you are traveling); or

3. Covered services are not available through a Medicare Select Hospital.

23

Plan AMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan A Pays You Pay

Hospitalization 5

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

First 60 days All but $1,364 $0 $1,364 (Part A deductible)

61st through 90th day All but $341 a day $341 a day $0

91st day and after:

– While using 60 Lifetime Reserve days All but $682 a day $682 a day $0

– Additional 365 days once Lifetime Reserve days are used $0

100% of Medicare- eligible expenses $0 6

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care 5

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

21st through 100th day All but $170.50 a day $0 Up to $170.50 a day

101st day and after $0 $0 All costs

Blood

First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0

Hospice CareYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

5 A benefit period begins on the first day you receive services 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.

6 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.

24

Plan AMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR.


Medical Expenses — In or Out of the Hospital and Outpatient Hospital Treatment, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (above Medicare-approved amounts)

$0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services — Tests for Diagnostic Services

100% $0 $0

MEDICARE (PARTS A & B)


Home Health Care Medicare-approved Services

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment

– First $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible)

– Remainder of Medicare-approved amounts

80% 20% $0

7 Once you have been billed $185 of Medicare-approved amounts for covered services, your Part B deductible will have been met for the calendar year.

25

Plan BMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan B Pays You Pay

Hospitalization 5


First 60 days All but $1,364 $1,364 (Part A deductible) 2

$0


91st day and after:


– Additional 365 days once Lifetime Reserve days are used

$0 100% of Medicare- eligible expenses

$0 6





21st through 100th day All but $170.50 a day $0 Up to $170.50 a day


Blood






$0

26

Plan BMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR



First $185 of Medicare-approved amounts 7

$0 $0 $185 (Part B deductible)

Remainder of Medicare-approved amounts

Generally 80% Generally 20% $0

Part B Excess Charges(above Medicare-approved amounts)

$0 $0 All costs

Blood


Next $185 of Medicare-approved amounts 7



80% 20% $0


100% $0 $0





100% $0 $0


– First $185 of Medicare-approved amounts 7



80% 20% $0

27

Plan CMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan C Pays You Pay

Hospitalization 5



$0


91st day and after:




$0 6





21st through 100th day All but $170.50 a day Up to $170.50 a day $0


Blood






$0

28

Plan CMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR



First $185 of Medicare-approved amounts 7 $0 $185 (Part B deductible) $0


Part B Excess Charges(above Medicare-approved amounts)

$0 $0 All costs

Blood


Next $185 of Medicare-approved amounts 7 $0 $185 (Part B deductible) $0



100% $0 $0





100% $0 $0


– First $185 of Medicare-approved amounts 7 $0 $185 (Part B deductible) $0

– Remainder of Medicare-approved amounts 80% 20% $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

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum

29

Plan FMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan F Pays You Pay

Hospitalization 5



$0


91st day and after:




$0 6







Blood






$0

30

Plan FMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR






$0 100% $0

Blood





100% $0 $0





100% $0 $0









31

High Deductible Plan FMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare PaysAfter You Pay $2,300 Deductible1, Plan F Pays

In Addition to $2,300 Deductible1, You Pay

Hospitalization 5


First 60 days All but $1,364 $1,364 (Part A deductible)

$0


91st day and after:




$0 6




First 20 days All approved amounts

$0 $0

21st through 100th day All but $170.50 a day

Up to $170.50 a day $0


Blood






$0

32

High Deductible Plan FMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR







$0 100% $0

Blood





100% $0 $0






100% $0 $0









33

Plan GMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan G Pays You Pay

Hospitalization 5



$0


91st day and after:




$0 6







Blood






$0

34

Plan GMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR






$0 100% $0

Blood





100% $0 $0




100% $0 $0


– First $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible)







35

Plan KMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan K Pays You Pay 3

Hospitalization 5


First 60 days All but $1,364 $682 (50% of Part A deductible) 8

$682 (50% of Part A deductible) *


91st day and after:




$0 6





21st through 100th day All but $170.50 a day Up to $85.25 a day Up to $85.25 a day *


Blood

First 3 pints $0 50% 50% *




50% of Medicare copayment/ coinsurance

50% of Medicare copayment/ coinsurance *

8 Medicare Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Medicare Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, Plan K pays 50% of the $1,364 deductible at any hospital from which you receive care.

36

Plan KMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR



First $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible) *

Preventive benefits for Medicare-covered services

Generally 75% or more of Medicare-approved amounts


All costs above Medicare- approved amounts

Remainder of Medicare-approved amounts Generally 80% Generally 10% Generally 10% *


$0 $0 All costs (and they do not count toward annual out-of-pocket limit 4 of $5,560)

Blood

First 3 pints $0 50% 50% *

Next $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible) *



100% $0 $0





100% $0 $0



$0 $0 $185 (Part B deductible) *


80% 10% Generally 10% *

37

Plan LMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan L Pays You Pay 3

Hospitalization 5


First 60 days All but $1,364 $1,023 (75% of Part A deductible) 9

$341 (25% of Part A deductible) *


91st day and after:




$0 6





21st through 100th day All but $170.50 a day Up to $127.88 a day Up to $42.62 a day *


Blood

First 3 pints $0 75% 25% *




75% of Medicare copayment/coinsurance

25% of Medicare copayment/coinsurance *

9 Medicare Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Medicare Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, Plan L pays 75% of the $1,364 deductible at any hospital from which you receive care.

38

Plan LMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR



First $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible) *

Preventive benefits for Medicare- covered services

Generally 75% or more of Medicare-approved amounts


All costs above Medicare- approved amounts



$0 $0 All costs (and they do not count toward annual out-of-pocket limit 4 of $2,780)

Blood

First 3 pints $0 75% 25% *

Next $185 of Medicare-approved amounts 7 $0 $0 $185 (Part B deductible) *



100% $0 $0





100% $0 $0



$0 $0 $185 (Part B deductible) *


80% 15% Generally 5% *

39

Plan NMEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD

Services Medicare Pays Plan N Pays You Pay

Hospitalization 5



$0


91st day and after:




$0 6







Blood






$0

40

Plan NMEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR


Medical Expenses — In or Out of the Hospital And Outpatient Hospital Treatment, such as physicians’ services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment


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 copayment 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 copayment 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.


$0 $0 All costs

Blood





100% $0 $0





100% $0 $0





80% 20% $0

41

Plan NOTHER BENEFITS – NOT COVERED BY MEDICARE






Important Information about Quotes for Medicare Supplement Quoted prices are based on the criteria specified during your search. This illustration is subject to Blue Cross and Blue Shield of Illinois’s rating or underwriting and approval, as appropriate, and does not guarantee rates, coverage or effective date. Furthermore, rates are subject to change if any of the information you have provided changes when and if a policy is approved. In addition, Blue Cross and Blue Shield of Illinois reserves the right to change rates from time to time. Not connected with or endorsed by the U.S. Government or Federal Medicare Program.

Medicare Supplement insurance plans are offered by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

outline of medicare supplement coverage — standard ...1 outline of medicare supplement coverage...

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