MEDICARE SUPPLEMENT INSURANCE - PDF Free Download

MEDICARE SUPPLEMENT INSURANCE New, Lower Cost Plans K and L Now Available! 30209.1205 IL From the Name You Can Trust for Stability and Value

IMPORTANT NOTE! A policy cannot be issued without all the required forms. For prompt application processing, PLEASE Mail application and all necessary forms to: Blue Cross and Blue Shield of Illinois P.O. Box 806162 Chicago, IL 60680-4123 Note to GA Producers: Please submit all new business to your General Agent. Be sure a Policy Checklist 30211.1105 - IL is completed in full and signed by both you and the applicant. The white copy must be returned with POLICY CHECKLIST AND the application; the yellow copy NOTICE OF REPLACEMENT INCLUDED HERE stays with the applicant. Be sure a Notice to Applicant Regarding Replacement OB2207 Rev. 6/05 is completed and signed if the applicant is replacing coverage. For your convenience, this form can be found near the back of this salespack as well as in this pocket. Be sure the Application OB3972 Rev. 1/06 is completed in full and signed. Pay special attention to Section C to ensure that the applicant includes his/her Medicare Claim Number. Thank You!

REMINDER: Don t forget to complete the policy checklist with your client and return the original with the application!

Carry this Card for Reliable Protection & Peace of Mind ADAMS, JANE Identification No. 069937 123456789 069937 S MED SUPP POLICY NO. CB 45.6 Group No. BC Plan Code 121 BS Plan Code 621 01-01-06 For more than 65 years, Illinois residents have turned to the comfort and security of Blue Cross and Blue Shield membership. We re proud that more than 300,000 of your Illinois neighbors age 65 and over count on the strength, stability, and affordable coverage offered by Blue Cross and Blue Shield of Illinois. When you choose Blue Cross and Blue Shield, you re assured of reliable coverage from a respected industry leader. Carry your Blue Cross and Blue Shield of Illinois card with confidence. It s your assurance that you control your health care with complete freedom to choose your own doctors and specialists. All at a price you can afford! In fact, when you see the premiums for our popular Med-Select option, you ll be surprised at just how affordable this coverage can be. Not only that, but today we re the largest health insurer in the state. We use our size and assets to provide you with value and outstanding customer service. When you need us, we ll be there for you just as we have been for over half a century. No matter where you go, our coverage will go with you. Our commitment to meeting the health insurance needs of our policyholders has made our card a recognized symbol of reliable health care coverage throughout Illinois, the U.S. and the world. Now, that s peace of mind.

Protect Yourself from the Bills Medicare Won t Pay Although Medicare pays some of your doctor and hospital bills, it was never meant to cover all of them. If you rely on Medicare alone to pay all your bills, you could be left with substantial out-of-pocket costs should you become hospitalized or need extensive outpatient treatment in 2006. Solid Protection Is Now More Important Than Ever For 2006, Medicare s deductibles and copayments, the costs you must pay, are higher than ever before. The fact is, you could face over $46,100 in bills that Medicare will not pay. And that doesn t even include doctor expenses under Medicare Part B or hospital expenses beyond 150 days. Now and in the years ahead, you can rely on our plans to cover the costs Medicare leaves you to pay. Every time Medicare raises your share of the costs, your Blue Cross and Blue Shield policy will adjust to help cover those increases. Choice of Plans Blue Cross and Blue Shield of Illinois has a choice of Medicare Supplement plans: Plan C features benefits for the $124 Part B deductible. Plan D covers at-home recovery benefits which could be important should an illness or injury one day leave you unable to care for yourself. Plan E features preventive care benefits. Preferred Plan F, our most popular plan, pays your $124 Part B deductible, plus 100% of your excess doctor charges. So even if your doctor charges more than the Medicare-approved amount, you won t pay a penny out of your own pocket! No other standardized Medicare Supplement plan offers more protection for your uncovered doctor and medical expenses. High Deductible Plan F is also available. It provides the same benefits as preferred Plan F but offers a lower premium by paying benefits after your out-of-pocket expenses reach $1,790 per calendar year. TWO Medicare Supplement Options, Standard Option or the Popular, Money-Saving Med-Select Option When you purchase Medicare Supplement Plan C, Plan D, Plan E, preferred Plan F, Plan K or Plan L, you may choose either the Standard or Med-Select option. Both options offer the same coverage. For example, with either option, if you select preferred Plan F, you will be covered for the $124 Part B deductible and 100% of excess charges. However, with Med-Select, your premiums will be less because you agree to use any one of our contracting We also offer Plan K and Plan L, which are lower-cost plan options. With these plans, you share in some of the costs for covered services until you meet an annual out-of-pocket limit. Once you meet the annual limit, the plan pays 100% of the Medicare deductibles and copayments for the rest of the calendar year. Coverage for All Medicare-Eligible Charges Blue Cross and Blue Shield provides coverage for all Medicare-eligible charges, including those for hospital care; office and home physician services; outpatient X-rays and lab tests; prosthetics and durable medical equipment; physical, radiation and speech therapy; chemotherapy; ambulance service; immunosuppressive drug therapy; and dressings, casts and braces. Guaranteed Acceptance You ll never have to answer health questions or take a physical exam. As long as you are an Illinois resident age 65 or over and are covered by Medicare Parts A and B, you will not be turned down for any reason including past or present medical conditions. Coverage Is Guaranteed Renewable This means Blue Cross and Blue Shield will never cancel your coverage because of changes in your health. As long as you pay your premium on time, your policy can never be canceled. No Lapse in Coverage if You Switch Plans There s no need to feel locked in to any coverage you may have currently. Blue Cross and Blue Shield of Illinois makes it easy to switch with absolutely no lapse in coverage. There is no waiting period for pre-existing health conditions. Save Money with the Med-Select Option! Med-Select hospitals for your non-emergency elective admissions. If you do not use one of these hospitals, you pay the $952 Part A deductible. It s that simple. See whether a hospital you would use is on our list. If it is, this money-saving option may be right for you. No matter which option you choose, you can depend on Blue Cross and Blue Shield protection whenever and wherever you need medical care. Please note: In order to be eligible to choose one of our Med-Select options, you must live within 30 miles of a contracting Med-Select hospital. If you do not live within 30 miles of a contracting Med-Select hospital, you are not eligible for this product. For additional information, please consult our Med-Select Contracting Hospital Listing.

Medicare Supplement Coverage Overview (Recommended Plans) PLAN F/ WHAT MEDICARE PLAN C PLAN D PLAN E HIGH DEDUCTIBLE PLAN K PLAN L LEAVES YOU TO PAY COVERS COVERS COVERS PLAN F COVER COVERS COVERS PART A $952 first-day deductible 2 Hospital 1 Care (50% of (75% of the cost) the cost) Charges for the first three pints of blood (50% of (75% of the cost) the cost) $238 per day for 61st 90th day in the hospital $476 per day for 91st 150th day in the hospital 100% of bills after day 150 in the hospital for an additional 365 days Skilled Nursing $119 per day for 21st 100th day Facility Care of a skilled nursing facility stay (50% of (75% of the cost) the cost) PART B $124 yearly deductible Physician Services Generally, 20% of the Medicare- eligible charges for physician (Generally (Generally and Supplies services and supplies 10% of 15% of the cost) the cost) Charges for the first three pints of blood (50% of (75% of the cost) the cost) Physician charges in excess of Medicare-approved amounts 3 Emergency 100% of bills 4 4 4 4 Care in a Foreign Country At-Home 100% of bills for at-home recovery 5 Recovery following a hospital stay Preventive Care 100% of bills 6 Annual Out-of-Pocket Maximum $0/$1,790 7 $4,000 8 $2,000 8 Note: The Blue Cross and Blue Shield of Illinois policies offered here meet state and federal government requirements for standardized Plan C (Part B deductible), Plan D (at-home recovery), Plan E (preventive care), Plan F and High Deductible Plan F (Part B deductible and 100% of excess charges; $1,790 annual out-of-pocket maximum with High Deductible Plan F), Plan K ($4,000 annual out-of-pocket maximum), and Plan L ($2,000 annual out-of-pocket maximum). 1 Hospital does not include a nursing home, convalescent home, extended care facility or psychiatric hospital. 2 Med-Select plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals to receive coverage for the Medicare Part A deductible, except in the event of emergency admission. 3 By law, no physician may charge more than 115% of Medicare-approved amounts. 4 Plan pays 80% of Medicare-eligible expenses after a $250 yearly deductible $50,000 lifetime total. 5 Plan pays up to $40 per day for at-home recovery care up to $1,600 per year; this care can include help with eating, dressing, bathing and taking medicine. 6 Plan pays 100% of costs, up to $120 a year for annual physical exams, hearing screenings, vaccines and other tests or preventive measures not covered by Medicare. 7 Our High Deductible Plan F offers the same benefits as our Plan F after you have paid a $1,790 calendar-year deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses are $1,790. 8 You will pay half the cost-sharing under Plan K and one fourth the cost sharing under Plan L for some covered services until you reach the annual out-ofpocket limit of $4,000 for Plan K or $2,000 for Plan L each calendar year. Once you reach the annual limit, both plans pay 100% of your Medicare copayments and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicareapproved amounts (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 Medicare for the item or service. The out-of-pocket limit will increase each year to keep pace with inflation.

See Why More Than 300,000 Illinois Residents Age 65 and Over Choose Blue Cross and Blue Shield of Illinois Choose Your Insurance Company Based on Price, Reputation and Service Insurance companies in Illinois can only offer standardized Medicare Supplement plans that have been approved by the National Association of Insurance Commissioners. Since the standardized Plan C, Plan D, Plan E, preferred Plan F, High Deductible Plan F, Plan K and Plan L presented here must be the same as Plan C, Plan D, Plan E, Plan F, High Deductible Plan F, Plan K and Plan L offered by other companies, you should choose your insurance company based on price, reputation and service. Considering these points, we think you will find Blue Cross and Blue Shield of Illinois is your best choice for coverage. Most Widely Recognized Coverage Available The Blue Cross and Blue Shield card is recognized by more doctors and hospitals than any other card of its kind. You can depend on Blue Cross and Blue Shield protection at home or when travelling. Commitment to Illinois Our Medicare Supplement coverage has been helping Illinois residents since Medicare began in 1966. We re financially strong and proud of our A+ (Superior) rating* from A.M. Best, one of the most experienced rating agencies of the insurance industry. Our strength and stability mean you can count on us in 2006, 2007 and every year thereafter. Freedom to Choose Your Own Doctors and Specialists Unlike Medicare HMOs that restrict your choice of doctors and specialists, with your Blue Cross and Blue Shield of Illinois Medicare Supplement plan, you are always free to choose any doctor or specialist you wish. There are no restrictions and you never need referrals. You control your health care! No Claim Forms Blue Cross and Blue Shield of Illinois handles all the paperwork and pays your doctor or hospital directly. There are no claim forms for you to complete, in most cases. 30-Day Guarantee of Satisfaction We want you to be 100% satisfied. If you should change your mind about your Blue Cross and Blue Shield of Illinois policy, even after you ve made your first premium payment, simply return your policy and membership card to your insurance representative within 30 days. If no claims were filed, you will get a refund of your premium. You ll be under no further obligation. Choice of Billing Options for Greater Ease and Flexibility Blue Cross and Blue Shield of Illinois gives you added flexibility and choice when it comes to paying your premiums. You can choose to be billed every two months, every six months or once a year. Simply indicate on your application which option you prefer. You also don t need to submit any payment with your application. Instead, when you receive your policy, an initial premium notice for the billing period that you ve selected will automatically be enclosed. All you have to do is send in your first payment, payable by either check or money order, no later than the date requested, and your coverage will be activated. It s that easy! And there s more. At the time you submit your initial payment, you can also decide to pay future premiums automatically with our monthly E-Z Blue SM Payment Option. Available at no extra cost, the E-Z Blue option allows you to authorize Blue Cross and Blue Shield of Illinois to withdraw the cost of premiums from your checking or savings account on a monthly basis. Nothing could be more convenient. Whichever payment option you choose, you ll have the peace of mind that comes from knowing your valuable Blue Cross and Blue Shield Medicare Supplement coverage is always with you. *As of June 2005

Save on vision care, dental care, hearing care, outpatient prescription drugs and more with Members First Members First can save you hundreds of dollars a year on products and services you use every day. There are no deductibles, no claim forms, and no dollar maximum limits. Use it as often as you need it! You re automatically enrolled in this money-saving discount program at no extra cost above your plan premium. With Members First you can: ADAMS, JANE Identification No. 123456789 Effective 01-01-06 Save as much as 30% on many brand-name and generic prescription drugs at nearly 40,000 participating pharmacies nationwide. Our network includes many major retail chains like Osco Drug, Dominick s, Kmart and Target, plus hundreds of local pharmacies. You can even have your prescriptions delivered to your door through our convenient mail order service. Save as much as 50% on dental care including routine and extensive dental care treatments at more than 15,000 providers nationwide. You ll receive your discount at the time of service. Save as much as 50% on vision care at more than 9,000 participating locations, including major names like LensCrafters, Sears, JCPenney and Pearle Vision. Save 50% 60% on contact lenses, eyeglasses and other retail eyewear items. Save as much as 20% on hearing services with discounts on hearing aids and other important products and services by licensed professional audiologists. Members receive a discount of as much as 20% on hearing aids. Save as much as 40% on chiropractic care with special discounted rates at more than 7,400 locations nationwide. With the Members First Chiropractic Program, there is unlimited access to care with no limits on the number of visits. Save on vitamins and nutritional supplements with discounts through mail order. Save on catalog prices 20% 50% below already reduced catalog prices. Save with FREE delivery of diabetes management products including blood glucose testing strips, lancets and lancet devices, insulin and syringes. There s no charge for shipping and you ll get a friendly reminder when it s time to reorder. Save with over $350 in grocery coupons. You choose the coupons you want from hundreds of nationally advertised brand names. Shop at your favorite grocery store and watch your savings add up! Members First: an Exclusive Privilege of Blue Cross and Blue Shield of Illinois Membership

A Word About Medicare Supplement Coverage By law, Illinois Insurance Companies must offer standardized plans from among the 12 developed by the National Association of Insurance Commissioners. These plans are identifiable by the letters A through L. Blue Cross and Blue Shield of Illinois, in accordance with state and federal standardization guidelines, began offering only standardized Medicare Supplement policies on January 1, 1992. The cover of the enclosed outline of coverage shows the main features of the 12 standardized plans. Our Standard and Med-Select options are identical in benefits, but our Med-Select option requires that you use a Blue Cross and Blue Shield of Illinois contracting Med-Select hospital for non-emergency admissions to receive coverage for the $952 Medicare Part A deductible. The plans Blue Cross and Blue Shield of Illinois offers are Plan C, which offers benefits for the $124 Part B deductible; Plan D, which offers benefits for at-home recovery; Plan E, which offers preventive care benefits; and preferred Plan F and High Deductible Plan F, which offer benefits for the $124 Part B deductible and any Part B charges in excess of the eligible amounts. We also offer Plan K and Plan L, which are lower-cost plan options. With these plans, you share in some of the costs for covered services until you meet an annual out-of-pocket limit. These plans are in the unshaded area of the chart, and were chosen because they provide significant coverage at a reasonable cost. By law, Plan A, which provides the lowest level of benefits, must be offered by all insurance companies. Plan A and High Deductible Plan F are available as Standard option plans only. More information on these plans is contained on the inside pages of the enclosed Outline of Coverage. Choose your Medicare Supplement insurance company based on price, company reputation and service. Since all plans are required to offer a standardized package of benefits, our Standard Plan C, Plan D, Plan E, preferred Plan F, High Deductible Plan F, Plan K and Plan L must be identical to the Standard Plan C, Plan D, Plan E, Plan F, High Deductible Plan F, Plan K and Plan L offered by other companies in Illinois. Therefore, your choice of an insurance company should be based on price, service, reputation and added features. We believe you ll find Blue Cross and Blue Shield of Illinois to be superior in each of these areas. If you have any questions about the enclosed Outline of Coverage, please feel free to contact your insurance representative.

Blue Cross and Blue Shield of Illinois Outline of Medicare Supplement Coverage Standard and Med-Select Benefit Plans B, C, D, E, F, High Deductible Plan F*, K and L Medicare Supplement insurance can be sold in only 12 standard plans, plus two high deductible plans. This chart shows the benefits included in each plan. Every company must make available Plan A. Blue Cross and Blue Shield of Illinois does not offer those plans shaded in gray below. BASIC BENEFITS: Hospitalization: Medical Expenses: Blood: Included in all plans. Plans K and L include benefits at different levels of cost sharing. Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Part B coinsurance (generally 20% of Medicare-approved expenses), or in the case of hospital outpatient department services under a prospective payment system, applicable copayments. First three pints of blood each year. A B C D E F F* G H I J J* K** L** Basic Benefits X X X X X X X X X X X X Skilled Nursing X X X X X X X X X X Coinsurance (50%) (75%) Part A X X X X X X X X X X X Deductible (50%) (75%) Part B X X X Deductible Part B X X X X Excess (100%) (80%) (100%) (100%) Foreign Travel X X X X X X X X Emergency At-Home Recovery X X X X Preventive Care X X Annual Out-of- $4,000*** $2,000*** Pocket Limit *Plans F and J also have an option called a high deductible Plan F* and a high deductible Plan J.* These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar-year $1,790 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses are $1,790. 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 plans separate foreign travel emergency deductible. OB3828 1/06 **Plans K and L provide for different cost-sharing for items and services from Plans A-J. Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles 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. ***The out-of-pocket annual limit will increase each year for inflation. 30219.1/06

2006 Monthly Premium Rates Rates 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. AGES OPTION C D E F F* K L Ages Standard $133.00 $114.00 $118.00 $135.00 $44.00 $69.00 $97.00 65-66 Med-Select $108.00 $93.00 $97.00 $114.00 N/A $63.00 $87.00 Ages Standard $151.00 $131.00 $137.00 $157.00 $51.00 $80.00 $113.00 67-69 Med-Select $125.00 $108.00 $111.00 $138.00 N/A $76.00 $105.00 Ages Standard $174.00 $151.00 $157.00 $185.00 $60.00 $94.00 $133.00 70-74 Med-Select $138.00 $119.00 $128.00 $152.00 N/A $84.00 $116.00 Ages Standard $200.00 $181.00 $187.00 $214.00 $69.00 $109.00 $154.00 75-79 Med-Select $150.00 $139.00 $143.00 $166.00 N/A $91.00 $126.00 80 and Standard $218.00 $209.00 $215.00 $226.00 $73.00 $115.00 $163.00 Over Med-Select $153.00 $158.00 $167.00 $169.00 N/A $93.00 $128.00 PREMIUM INFORMATION Blue Cross and Blue Shield of Illinois can only raise your premium if we raise the premium for all policies like yours in this state. We will not change your premium or cancel your policy because of poor health. Premiums change at age 67, 70, 75 and 80. If your premium changes, you will be notified at least 30 days in advance. Rates for Plan A**: ages 65-66: Standard $66.00, ages 67-69: Standard $78.00, ages 70-74: Standard $86.00, ages 75-79: Standard $101.00, ages 80+: Standard $115.00, **Med-Select option not available under Plan A Rates for Plan B: ages 80 + : Standard $212.00, Med-Select $159.00. 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 Med-Select Plans, with the exception of Plan A and High Deductible Plan F,* which are available as Standard Plans only. Med-Select Plans require that you use a Blue Cross and Blue Shield of Illinois contracting Med-Select hospital for non-emergency admissions to receive coverage for the Medicare Part A deductible. *This high deductible plan pays the same benefits as Plan F after one has paid a calendar-year $1,790 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses are $1,790. 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.

Plan B MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. 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. SERVICES MEDICARE PAYS PLAN B COVERS WITH PLAN B YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $952 (Part A deductible)** $0 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day $0 Up to $119 a day 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN B COVERS WITH PLAN B YOU PAY HOSPICE CARE Available as long as your doctor certifies you All but very limited $0 Balance are terminally ill and you elect to receive coinsurance for these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN B COVERS 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 $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES $0 $0 All costs (above Medicare-approved amounts) BLOOD First three pints $0 All costs $0 Next $124 of Medicare-approved amounts* $0 $0 $124 (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) SERVICES MEDICARE PAYS PLAN B COVERS WITH PLAN B YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0

Plan C MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. 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. SERVICES MEDICARE PAYS PLAN C COVERS WITH PLAN C YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $952 (Part A deductible)** $0 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $119 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN C COVERS WITH PLAN C YOU PAY HOSPICE CARE Available as long as your doctor certifies you All but very limited $0 Balance are terminally ill and you elect to receive coinsurance for these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN C COVERS 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 $124 of Medicare-approved amounts* $0 $124 (Part B deductible) $0 Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES $0 $0 All costs (above Medicare-approved amounts) BLOOD First three pints $0 All costs $0 Next $124 of Medicare-approved amounts* $0 $124 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN C COVERS WITH PLAN C YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $124 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN C COVERS 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 20% and amounts over maximum benefit the $50,000 lifetime of $50,000 maximum

Plan D MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. 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. SERVICES MEDICARE PAYS PLAN D COVERS WITH PLAN D YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $952 (Part A deductible)** $0 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $119 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN D COVERS WITH PLAN D YOU PAY HOSPICE CARE Available as long as your doctor certifies you All but very limited $0 Balance are terminally ill and you elect to receive coinsurance for these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN D COVERS WITH PLAN D 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 $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES $0 $0 All costs (above Medicare-approved amounts) BLOOD First three pints $0 All costs $0 Next $124 of Medicare-approved amounts* $0 $0 $124 (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) SERVICES MEDICARE PAYS PLAN D COVERS WITH PLAN D YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 AT-HOME RECOVERY SERVICES NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a home care treatment plan Benefit for each visit $0 Actual charges to $40 Balance a visit Number of visits covered (must be $0 Up to the number of received within eight weeks of last Medicare-approved visit) Calendar-year maximum $0 $1,600 Medicare-approved visits, not to exceed seven each week OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN D COVERS WITH PLAN D 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 20% and amounts over maximum benefit the $50,000 lifetime of $50,000 maximum

Plan E MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. 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. SERVICES MEDICARE PAYS PLAN E COVERS WITH PLAN E YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $952 (Part A deductible)** $0 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $119 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN E COVERS WITH PLAN E YOU PAY HOSPICE CARE Available as long as your doctor certifies you All but very limited $0 Balance are terminally ill and you elect to receive coinsurance for these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN E COVERS WITH PLAN E 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 $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES $0 $0 All costs (above Medicare-approved amounts) BLOOD First three pints $0 All costs $0 Next $124 of Medicare-approved amounts* $0 $0 $124 (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) SERVICES MEDICARE PAYS PLAN E COVERS WITH PLAN E YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE *Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. SERVICES MEDICARE PAYS PLAN E COVERS WITH PLAN E 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 20% and amounts over maximum benefit the $50,000 lifetime of $50,000 maximum *PREVENTIVE MEDICAL CARE BENEFIT NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare First $120 each calendar year $0 $120 $0 Additional charges $0 $0 All costs

PLAN F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. 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. SERVICES MEDICARE PAYS PLAN F COVERS WITH PLAN F YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $952 (Part A deductible)** $0 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $119 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN F COVERS WITH PLAN F YOU PAY HOSPICE CARE Available as long as your doctor certifies you All but very limited $0 Balance are terminally ill and you elect to receive coinsurance for these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN F COVERS 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 $124 of Medicare-approved amounts* $0 $124 (Part B deductible) $0 Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES $0 100% $0 (above Medicare-approved amounts) BLOOD First three pints $0 All costs $0 Next $124 of Medicare-approved amounts* $0 $124 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

High Deductible Plan F MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. 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. SERVICES MEDICARE PAYS PLAN F COVERS WITH PLAN F YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $952 (Part A deductible) $0 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $119 a day $0 101st day and after $0 $0 All costs BLOOD First three pints $0 Three pints $0 Additional amounts 100% $0 $0

MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN F COVERS WITH PLAN F YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $124 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN F COVERS 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 20% and amounts over maximum benefit the $50,000 lifetime of $50,000 maximum This high deductible plan pays the same benefits as Plan F after one has paid a calendar-year $1,790 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses are $1,790. 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.

Plan K MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,000 each calendar year. The amounts that count toward your annual limit are noted with ( ). 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. SERVICES MEDICARE PAYS PLAN K COVERS WITH PLAN K YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $476 $476 (50% of Part A deductible)** (50% of Part A deductible)** 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $59.50 a day Up to $59.50 a day 101st day and after $0 $0 All costs BLOOD First three pints $0 50% 50% Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, 50% of the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN K COVERS WITH PLAN K YOU PAY HOSPICE CARE Available as long as your doctor All but very limited 50% of coinsurance or 50% of coinsurance or certifies you are terminally ill and coinsurance for copayments copayments you elect to receive these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,000 each calendar year. The amounts that count toward your annual limit are noted with ( ). SERVICES MEDICARE PAYS PLAN K COVERS WITH PLAN K 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 $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 10% Generally 10% PART B EXCESS CHARGES (above Medicare-approved amounts) $0 $0 All costs BLOOD First three pints $0 50% 50% Next $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% Generally 10% Generally 10% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN K COVERS WITH PLAN K YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% 10% 10% OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN K COVERS WITH PLAN K 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 $0 All costs

PLAN L MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD* *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. You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,000 each calendar year. The amounts that count toward your annual limit are noted with ( ). 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. SERVICES MEDICARE PAYS PLAN L COVERS WITH PLAN L YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $952 $714 $238 (75% of Part A deductible)** (25% of Part A deductible)** 61st through 90th day All but $238 a day $238 a day $0 91st day and after: While using 60 Lifetime Reserve days All but $476 a day $476 a day $0 Once Lifetime Reserve days are used: Additional 365 days $0 100% of Medicare- $0 eligible expenses 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 Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st through 100th day All but $119 a day Up to $89.25 a day Up to $29.75 a day 101st day and after $0 $0 All costs BLOOD First three pints $0 75% 25% Additional amounts 100% $0 $0 **Med-Select Plans require that you use Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals for non-emergency admissions to receive coverage for the Medicare Part A deductible. In an emergency, 75% of the $952 deductible is covered at any hospital from which you receive care.

MEDICARE (PART A) HOSPITAL SERVICES PER BENEFIT PERIOD (continued) SERVICES MEDICARE PAYS PLAN L COVERS WITH PLAN L YOU PAY HOSPICE CARE Available as long as your doctor All but very limited 75% of coinsurance or 25% of coinsurance or certifies you are terminally ill and coinsurance for copayments copayments you elect to receive these services outpatient drugs and inpatient respite care MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR *Once you have been billed $124 of Medicare-approved amounts for covered services (which are noted with a single asterisk), your Part B deductible will have been met for the calendar year. You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,000 each calendar year. The amounts that count toward your annual limit are noted with ( ). SERVICES MEDICARE PAYS PLAN L COVERS WITH PLAN L 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 $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Preventive benefits for Medicare-covered Generally 75% or more Remainder of Medicare- $0 services of Medicare-approved approved amounts amounts Remainder of Medicare-approved amounts Generally 80% Generally 15% Generally 5% PART B EXCESS CHARGES $0 $0 All costs (above Medicare-approved amounts) BLOOD First three pints $0 75% 25% Next $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% Generally 15% Generally 5% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN L COVERS WITH PLAN L YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable medical equipment First $124 of Medicare-approved amounts* $0 $0 $124 (Part B deductible) Remainder of Medicare-approved amounts 80% 15% 5% OTHER BENEFITS NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN L COVERS WITH PLAN L 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 $0 All costs

DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN YOUR POLICY If you find that you are not satisfied with your policy, you may return it to Blue Cross and Blue Shield of Illinois, P.O. Box 806162, Chicago, IL 60680-4123. 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. MED-SELECT ADDITIONAL DISCLOSURES GRIEVANCE PROCEDURES Our 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 Med-Select coverage, please send all written grievances within 60 days of the occurrence of your dissatisfaction to: Blue Cross and Blue Shield of Illinois, Medicare Select Program, P.O. Box 1637, Chicago, Illinois 60690-1637. 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. 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. Blue Cross and Blue Shield of Illinois is not 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 IMPORTANT Review the application carefully before you sign it. Be certain that all information has been properly recorded. QUALITY ASSURANCE As 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. MED-SELECT HOSPITAL RESTRICTIONS Plans B, C, D, E, F, K and L are Med-Select policies currently available. Part A benefits may be restricted if you receive services in a hospital that is not a Med-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 Med-Select Hospital (such as while you are traveling); or 3. Covered services are not available through a Med-Select Hospital.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association CONSUMER MARKETS Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans BPROC026

NOTES

Exclusions and Limitations The policy covers only Medicare-eligible charges, and coverage is limited to the services and supplies mentioned in the policy. Other services not covered are the following: treatment of injuries or illnesses which are related to employment or covered by an insurance or workers compensation law; treatment covered or provided by Government Programs except for medical assistance under Article V, VI, or VII of the Illinois Public Aid Code; treatment for injuries or illnesses caused by war or any act of war whether declared or undeclared; treatment received from medical and dental departments maintained by or for an employer, a mutual benefit association, a labor union, a trustee, or similar entity; free treatment or treatment that would have been free if not insured under the policy; custodial care; services you no longer need; routine physical examinations; cosmetic surgery except oral surgery; eye exams, eyeglasses or contact lenses; hearing aids or exams for their prescription and fitting; routine foot care or the treatment of flat feet or subluxations of the foot; fees charged to complete a claim form or to compensate for a missed scheduled appointment; services performed by a member of your immediate family; and outpatient prescription drugs. Policy is cancelable only for non-payment of premium or material misrepresentation. With our Med-Select coverage option, you must use one of the Blue Cross and Blue Shield of Illinois contracting Med-Select hospitals to receive benefits for the $952 Part A deductible. (This does not apply in cases of emergency admission.) If you do not use a contracting Med-Select hospital for non-emergency admissions, you will be responsible for the Part A deductible.