BlueCare Policy Comparison Chart Effective January 1, 2019 BlueCare Part A Hospital Insurance Covered Services

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1 SERVICE MEDICARE PLAN A Hospitalization Semiprivate room and board. General nursing and miscellaneous hospital services and supplies. Network Hospital First 60 s BlueCare Policy Comparison Chart Part A Hospital Insurance Covered Services PLAN B PLAN C PLAN D PLAN F All but $1,364 (Part A $0 $1,364 (Part A $1,364 (Part A $1,364 (Part A $1,364 (Part A $1,364 (Part A $1,364 (Part A $1,023 (75% of $1,364 (Part A the Part A 61 st to 90 th All but $341 a $341 a $341 a $341 a $341 a $341 a $341 a $341 a $341 a $341 a 91 st and after: While using 60 lifetime reserve s Once lifetime reserve s are used: Additional 365 s All but $682 a $682 a $682 a $682 a $682 a $682 a $682 a $682 a $682 a $682 a $0 eligible eligible eligible eligible eligible eligible eligible eligible Beyond the additional 365 s $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Skilled Nursing Care must approve the facility and you must have been in the hospital at least three s. First 20 s All approved $0 $0 $0 $0 $0 $0 $0 $0 $0 eligible 21 st through 100 th All but $ a $0 $0 Up to $ a Up to $ a Up to $ a Up to $ a Up to $ a Up to $ a Up to $ a 101 st and after $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Blood $0 Three pints Three pints Three pints Three pints Three pints Three pints Three pints 75% of first Three pints First three pints three pints Additional 100% $0 $0 $0 $0 $0 $0 $0 $0 $0 Hospice Care Must be terminally ill All but very limited for outpatient drugs and respite care 75% of the

2 SERVICE MEDICARE PLAN A Medical Expenses Physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $185 of approved (Part B Preventive benefits for -covered services Remainder of approved $0 $0 $0 $185 (Part B BlueCare Policy Comparison Chart Part B Medical Insurance Covered Services PLAN B PLAN C PLAN D PLAN F $0 $185 (Part B $185 (Part B $0 $0 $0 Generally 80% or more of -approved 20% 20% 20% 20% 20% 20% 20% 15% 20% Generally 80% 20% 20% 20% 20% 20% 20% 20% 15% Balance of the approved amount after a $20 copayment for office visits. Balance of the approved amount after a $50 copayment for emergency room visits. The emergency room copayment is waived if you are admitted to the hospital and the emergency visit is covered as a Part A.

3 BlueCare Policy Comparison Chart Part B Medical Insurance Covered Services SERVICE MEDICARE PLAN A PLAN B PLAN C PLAN D PLAN F Part B Excess Charges $0 $0 $0 $0 $0 100% 100% 100% $0 $0 Above -approved Blood $0 All costs All costs All costs All costs All costs All costs All costs 75% of the first All costs First three pints three pints Next $185 of -approved $0 $0 $0 $185 (Part B $0 $185 (Part B $185 (Part B $0 $0 $0 (Part B Remainder of -approved Generally 80% 20% 20% 20% 20% 20% 20% 20% 15% 20% Clinical Laboratory Services Tests for diagnostic services 100% $0 $0 $0 $0 $0 $0 $0 $0 $0 Part A & B Covered Services Home Healthcare - 100% $0 $0 $0 $0 $0 $0 $0 $0 $0 Approved Services Medically necessary skilled care services and medical supplies Durable medical equipment: - First $185 of approved (Part B - Remainder of approved $0 $0 $0 $185 (Part B $0 $185 (Part B $185 (Part B $0 $0 $0 Generally 80% 20% 20% 20% 20% 20% 20% 20% 15% 20% Other Services Not Covered by Foreign Travel Medically necessary emergency services during the first 60 s of each trip outside the USA: - First $250 each calendar year $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 - Remainder of charges $0 $0 $0 maximum benefit of $50,000 $0

4 BlueCare Policy Comparison Chart *Out-of-Pocket Maximum PLAN C PLAN D PLAN F SERVICE MEDICARE PLAN A PLAN B N/A N/A N/A N/A N/A N/A $2,300* N/A $2,780** N/A * Plan F also has an option called a high deductible plan F. 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 s exceed $2,300. Out-of-pocket s for this deductible are s that would ordinarily be paid by the policy. These s include the deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. **For Plan L you will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,780 each calendar year. Once you reach the annual limit, the plan pays 100 percent of your copayment and for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed -approved (these are called Excess Charges ) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by for the item or service.

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