MedigapSecurity Plan Information. Individual supplement plan options for people with Medicare. MedigapSecurity 5822(10/15)BKV1

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1 2016 MedigapSecurity Plan Information Individual supplement plan options for people with Medicare MedigapSecurity 5822(10/15)BKV1

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3 Thank you. We appreciate your interest in Independence Blue Cross. We look forward to serving you as one of the many members who ve chosen us for our stability, reliability, and large network of preferred doctors and hospitals. This booklet provides you with information on our MedigapSecurity, our Medicare Supplement plans, also known as Medigap. Take a few minutes to look through it and decide which plan best fits your needs and budget. Of course, you can call us with any questions about plan coverage, including monthly premiums and cost-sharing. We ve included an enrollment form for your convenience. Simply complete the form and return it in the postage-paid reply envelope provided. Thanks again for requesting this information and for choosing Independence Blue Cross. Questions? Call Independence Blue Cross at (TTY/TDD:711) Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voic . Connect with us on Facebook: Contents Introduction Benefits at a glance Ready to enroll? Replacement notice Outline of coverage

4 3 steps to finding the right Medigap plan Follow these steps to find a Medicare supplement plan that fits your budget, needs, and lifestyle Learn about the plans we offer Compare benefits, cost-sharing, and premiums Enroll in the plan you want Let s get started Independence Blue Cross and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association.

5 Take a look at these 2 types of plans. They cover the costs not covered by Original Medicare. Medicare Advantage Plans These plans are offered by private insurance companies that are approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You ll get your Medicare Part A and Medicare Part B coverage from the Medicare Advantage plan. Medicare Advantage Plans must cover all of the services that Original Medicare covers. Medicare Advantage plans are not considered Medicare Supplement plans. Medicare Supplement Plans (Medigap) With this option, you remain enrolled in Original Medicare. When you buy a Medicare Supplement plan from a private insurance company, Original Medicare will pay its share of costs for covered services, then your supplement plan will pay its share. These plans do not include prescription drug coverage. While your monthly premium may be higher than a Medicare Advantage plan, many people choose them for lower copays, deductibles and coinsurance.

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7 IN THIS SECTION Benefits at a glance

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9 How to pick a plan: If you want the freedom to see any provider, this is your plan. Help protect yourself from the deductibles, copayments, and coinsurance not covered by Original Medicare. MedigapSecurity offers a choice of six (A, B, C, F, F High Deductible, and N) Medicare Supplement insurance (Medigap) plans that give you the freedom you want and the protection you need. Questions? Call Independence Blue Cross at (TTY/TDD:711) Seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voic . Or visit us online at Connect with us on Facebook:

10 With MedigapSecurity: You re free to visit any doctor who accepts Original Medicare. There s no need to select a primary care physician. You don t need a referral to see a specialist. You re covered when you travel in the United States. There are virtually no claim forms. You get emergency coverage outside of the United States (with plan C, F, and N). You ll also have access to our Healthy Lifestyles SM Solutions: Tobacco Cessation Program You may receive up to $150 reimbursement for completing an approved tobacco cessation program. Weight Management Program You may also receive up to $150 reimbursement for participating in an approved weight management program. Fitness Reimbursement Up to $150 reimbursement after 120 workouts in 365 days at an approved gym. Plus, you ll receive TruHearing discounts: TruHearing provides dicounted rates on hearing aids through a national provider network. TruHearing is a registered trademark of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners.

11 Terms to know: This quick list of Medicare-related terms will help you better understand the information in this Plan Information Book. Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. Coinsurance: An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Copayment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor s visit or prescription drug. Premium: The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage.

12 MEDICARE SUPPLEMENT PLANS Your MedigapSecurity Plan Choices Service category Medicare pays: Plan A You pay: Plan B You pay: Plan C You pay: Primary Care Physician Visits Specialist Visits Emergency Room 80% of Medicare-approved amounts after $147 annual Part B deductible is met $147 Part B deductible (Plan pays 20% coinsurance) $147 Part B deductible (Plan pays 20% coinsurance) $0 (Plan pays Part B deductible and 20% coinsurance) Urgent Care Outpatient Surgery Inpatient Hospital All charges except $1,260 (Part A deductible) and Part A coinsurance $1,260 (Part A deductible) $0 $0 Part B Excess Charges Nothing 100% 100% 100% Prescription Drugs (Part D) Nothing Prescription Drug coverage is not included Monthly Rates for Plans A, B, and C (per person) effective April 1, 2015 Plan A Plan B Plan C First eligible or current subscriber $ $ $ Ages $ $ $ Ages $ $ $ Ages 80 and over $ $ $ Medicare disabled who are not first eligible $ $ $ Rates are subject to change. With Plans A, B, and C, your monthly premium is based on your age when you first enroll. Rates may change to keep pace with Medicare increases or based on claims experience, but it will not change simply because you get older. Your rate will not increase when you move into the next age bracket.

13 Your MedigapSecurity Plan Choices Plan F*/ Plan F High Deductible** You pay: $0 (Plan pays Part B deductible and 20% coinsurance) Plan N* You pay: $147 Part B deductible; up to a $20 copay for doctor visits; up to a $50 copay for emergency room (waived if admitted) (Plan pays all other Part B coinsurance) $0 $0 $0 100% Prescription Drug coverage is not included * Available only to beneficiaries who enroll within six months following enrollment in Medicare Part B, or who are guaranteed the right to purchase these plans under applicable federal or state laws. ** Plan F High Deductible pays the same benefits as Plan F after members have paid a $2,180 calendar year deductible. Benefits from Plan F High Deductible will not begin until out-of-pocket expenses exceed $2,180. Rates for Plan F High Deductible are approximately 50% lower than Plan F. The calendar year deductible is subject to change in This is the 2015 amount and may change on January 1, Each year, Social Security notifies all Medicare beneficiaries of the new Part A deductible and coinsurance, Part B deductible and Part B premium amount. If the amount a doctor or other health care provider charges is higher than the Medicare-approved amount, the difference is called the excess charge. Monthly Rates for Plans F, F High Deductible, and N Plan F (per person) effective January 1, 2014 Plan F High Deductible Plan N Up to age 69 $ $ $ Ages $ $ $ Ages $ $ $ Ages $ $ $ Ages 85+ $ $ $ Under 65 late entry $ $ $ Rates are subject to change. With Plans F, F High Deductible, and N, your monthly premium increases as you enter each new age band, but you cannot be singled out for a rate increase (or your policy cancelled) because of poor health. MedigapSecurity is not connected with or endorsed by the U.S. government or the federal Medicare program. To join, you must be enrolled in Medicare Parts A and B. Plan F and Plan N are available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. You must continue to pay Medicare Part A (if applicable) and Part B premiums.

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15 IN THIS SECTION Ready to enroll?

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17 Ready to sign up for a MedigapSecurity plan? Here are easy step-by-step instructions for filling out the enrollment form. SECTION Personal Information A Please check [ ] the box in front of the MedigapSecurity plan you want to enroll in. Then provide the personal information requested. REMINDER: You must be within 6 months of your Medicare Part B effective date to enroll in Plan F or Plan N. Please see the enclosed insert Your Rights to Guaranteed Issue of Medicare Supplemental Policies for exceptions. SECTION B Medicare Insurance Information You will need your Medicare card to complete this section. You must include your Medicare claim number on your application form. SECTION C Your Plan Premium Please answer the questions in this section. SECTION D Important Questions Please read the important information regarding eligibility. SECTION E Your Signature Please read the information provided, then sign and date your enrollment form. If you are an authorized representative, please provide the information requested. Applicants have a right to return this Policy within (30) days of delivery for refund of the full premium paid if, after examination of this Policy, the Applicant is not satisfied for any reason. This Policy may be returned to Independence Blue Cross Plans, 1901 Market Street, Philadelphia, Pa If the Policy is returned, it will be null and void from the beginning and no benefits will be payable under its terms. Questions? Call Independence Blue Cross at (TTY/TDD:711) 7 days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voic . Connect with us on Facebook: MedigapSecurity is not connected with or endorsed by the U.S. government or the federal Medicare program. 5822(10/15)EI

18 MedigapSecurity NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE Independence Blue Cross 1901 Market Street Philadelphia, PA SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage and replace it with a policy to be issued by Independence Blue Cross and Highmark Blue Shield. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy. You should review this coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. STATEMENT TO APPLICANT BY ISSUER, PRODUCER (OR OTHER REPRESENTATIVE): I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one): Additional benefits. No change in benefits, but lower premium. Fewer benefits and lower premiums. My plan has an outpatient prescription drug coverage and I am enrolling in Part D. Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment: Other. (please specify) 08497

19 Signature of producer or other representative (A signature is not required for direct response sales). Typed Name and Address of issuer, producer or other representative Applicant s Signature Date 1. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. 2. State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. 3. Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. Independence Blue Cross and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association Not connected with or endorsed by the U.S. Government or the federal Medicare program.

20 MedigapSecurity NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE Independence Blue Cross 1901 Market Street Philadelphia, PA SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage and replace it with a policy to be issued by Independence Blue Cross and Highmark Blue Shield. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy. You should review this coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. STATEMENT TO APPLICANT BY ISSUER, PRODUCER (OR OTHER REPRESENTATIVE): I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one): Additional benefits. No change in benefits, but lower premium. Fewer benefits and lower premiums. My plan has an outpatient prescription drug coverage and I am enrolling in Part D. Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment: Other. (please specify) 08497

21 Signature of producer or other representative (A signature is not required for direct response sales). Typed Name and Address of issuer, producer or other representative Applicant s Signature Date 1. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy. 2. State law provides that your replacement policy or certificate may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. 3. Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. Independence Blue Cross and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association Not connected with or endorsed by the U.S. Government or the federal Medicare program.

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23 Independence Blue Cross and Highmark Blue Shield Outline of Medicare Supplement Coverage MedigapSecurity Plans A, B, C, F, F High Deductible and N Benefit Chart of Medicare Supplement Plans sold on or After June 1, 2010 This chart shows the benefits included in each of Basic Benefits: the standard Medicare supplement plans. Every Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end company must make Plans A, B, and C or F Medical expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital available. Some plans may not be available in outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. your state. Plans E, H, I, and J are no longer Blood: First three pints of blood each year available for sale. Hospice: Part A coinsurance A B C D F 1 F* G K L M N 1 Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Part A Deductible Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess (100%) Foreign Travel Emergency Hospitalization 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 $4,940; paid at 100% after limit reached Hospitalization 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 $2,470; paid at 100% after limit reached Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency 1 Available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. * 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 $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. Page 1 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

24 INDEPENDENCE BLUE CROSS/HIGHMARK BLUE SHIELD MEDIGAPSECURITY PREMIUM INFORMATION Independence Blue Cross and Highmark Blue Shield can only raise your premium if we raise the premium for all policies like yours in our services area. We will not change your premium or cancel your policy because of poor health. These monthly rates are subject to change with the approval of the Pennsylvania Insurance Department. Issue Age First Eligible or Current Subscriber Ages Ages Ages 80 and over Medicare Disabled who are not First Eligible MedigapSecurity Plan A $ $ $ $ $ MedigapSecurity Plan B $ $ $ $ $ MedigapSecurity Plan C $ $ $ $ $ Attained Age Ages 0-64 Ages Ages Ages Ages Ages 85 + Under 65 Late Entry MedigapSecurity Plan F 1 $ $ $ $ $ $ $ MedigapSecurity Plan F High Deductible $ $ $ $ $ $ $ MedigapSecurity Plan N 1 $ $ $ $ $ $ $ Available only to applicants who enroll within six months following enrollment in Medicare Part B or who are guaranteed the right to purchase these plans under applicable federal or state laws. Page 2 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

25 PREMIUM INFORMATION We, Independence Blue Cross and Highmark Blue Shield, can only raise your premium if we raise the premium for all policies like yours in the Commonwealth of Pennsylvania. Premiums for attained age plans F, F High Deductible, and N will increase beginning with the first full month that the member moved into a new age range in accordance with the premium schedule on the previous page. Disclosures Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I and J are no longer available for sale. 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 YOUR POLICY If you find that you are not satisfied with your policy, you may return it to Independence Blue Cross and Highmark Blue Shield, 1901 Market Street, Philadelphia, PA 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. Independence Blue Cross and Highmark Blue Shield are not connected with Medicare. This Outline of Coverage does not give all of the details of Medicare coverage. Contact your local Social Security office or consult Medicare & You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT Review the application carefully before you sign it. Be certain that all information has been properly recorded. Page 3 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

26 MedigapSecurity Plan A * 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. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $0 $1,260 (Part A deductible) 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o 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 three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $ a day $0 Up to $ a day 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You 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** $0 **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. (continued) Page 4 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

27 MedigapSecurity Plan A (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A, YOU PAY 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 $147 of Medicare-approved amounts $0 $0 $147 (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 three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A, YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Page 5 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

28 MedigapSecurity Plan B * 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. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o 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 three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $ a day $0 Up to $ a day 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You 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** $0 **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. (continued) Page 6 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

29 MedigapSecurity Plan B (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B, YOU PAY 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 $147 of Medicare-approved amounts $0 $0 $147 (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 three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B, YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 Page 7 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

30 MedigapSecurity Plan C * 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. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN C PAYS WITH PLAN C, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o 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 three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You 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** $0 **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. (continued) Page 8 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

31 MedigapSecurity Plan C (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN C PAYS WITH PLAN C, YOU PAY 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 $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN C PAYS WITH PLAN C, YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN C PAYS WITH PLAN C, YOU PAY 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 20% and amounts over the of $50,000 $50,000 lifetime maximum Page 9 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

32 MedigapSecurity Plan F * 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. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o 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 three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You 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** $0 **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. (continued) Page 10 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

33 MedigapSecurity Plan F (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, YOU PAY 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 $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, YOU PAY 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 20% and amounts over the of $50,000 $50,000 lifetime maximum Page 11 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

34 MedigapSecurity Plan F HIGH DEDUCTIBLE * 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. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS AFTER YOU PAY $2,180 IN ADDITION TO $2,180 DEDUCTIBLE, PLAN F PAYS DEDUCTIBLE, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o 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 three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 $0** **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. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,180. 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. (continued) Page 12 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

35 MedigapSecurity Plan F HIGH DEDUCTIBLE (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS AFTER YOU PAY $2,180 DEDUCTIBLE, PLAN F PAYS Medicare copayment/coinsurance HOSPICE CARE You 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 (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS AFTER YOU PAY $2,180 DEDUCTIBLE, PLAN F PAYS 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 $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES BLOOD TESTS FOR 100% $0 $0 DIAGNOSTIC SERVICES IN ADDITION TO $2,180 DEDUCTIBLE, YOU PAY $0 IN ADDITION TO $2,180 DEDUCTIBLE, YOU PAY This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,180. 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. (continued) Page 13 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

36 MedigapSecurity Plan F HIGH DEDUCTIBLE (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS AFTER YOU PAY $2,180 DEDUCTIBLE, PLAN F PAYS HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $147 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS AFTER YOU PAY $2,180 DEDUCTIBLE, PLAN F PAYS 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 of $50,000 IN ADDITION TO $2,180 DEDUCTIBLE, YOU PAY IN ADDITION TO $2,180 DEDUCTIBLE, YOU PAY 20% and amounts over the $50,000 lifetime maximum This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,180. 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. Page 14 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

37 MedigapSecurity Plan N * 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. MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st through 90th day All but $315 a day $315 a day $0 91st day and after: While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare-eligible expenses o 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 three days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You 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 **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. (continued) $0** $0 Page 15 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

38 MedigapSecurity Plan N (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, YOU PAY 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 $147 of Medicare-approved amounts $0 $0 $147 (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 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. Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints $0 All costs $0 Next $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES BLOOD TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 Page 16 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

39 MedigapSecurity Plan N (continued) Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $147 of Medicare-approved amounts $0 $0 $147 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, YOU PAY 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 20% and amounts over the of $50,000 $50,000 lifetime maximum Page 17 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

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42 Questions? Need more information? Call one of our Medicare sales representatives at (TTY/TDD: 711) Seven days a week, 8 a.m. to 8 p.m. Independence Blue Cross and Highmark Blue Shield are independent licensees of the Blue Cross and Blue Shield Association. MS6698 (1/15) Page 20 POLICY FORM #5450-OC Rev. 1/15 INDIVIDUAL

43 INSIDE BACK COVER

44 MedigapSecurity