Premera Blue Cross MEDICARE SUPPLEMENT PLANS

Discover a plan thats right for you.

Benefit Highlights

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

BHBMSWA (06-2015)

2017

Effective MARCH

You can count on us

The Premera Blue Cross Medicare Supplement plan portfolio was created based on the plan preferences our members have shown. With these plans, you can count on:

The freedom to use any doctor or hospital that accepts Medicare

Knowing that your plan is guaranteed renewable and portable

Knowing that your coverage wont be terminated if your health changes

Nationwide coverage when you travel

Youve worked hard to act any age you want. Now is the time when freedom is yours.

Premera Blue Cross Medicare Supplement plans help you enjoy it

Our Medicare Supplement plans give you peace of mind about your healthcare coverage throughout your retirement. They cover the growing costs Original Medicare alone leaves you to pay, and give you the freedom to see any doctor who accepts Medicare.

Premera Blue Cross is a trusted name in healthcare and being helpful is number one in our book. Use the expertise of our highly-trained, local representatives to assist you in choosing the plan thats right for you. And know that if you ever have questions about the best way to use your plan, were here to help.

Premera Medicare Supplement PlansA Medicare Supplement plan can help pay some of the healthcare costs that Original Medicare doesnt cover, like copayments, coinsurance, and deductibles. Some Medicare Supplement plans also offer coverage for services that Original Medicare doesnt cover, like medical care when you travel outside of the United States. If you have Original Medicare and you buy a Medicare Supplement plan, Medicare will pay its share of the Medicare-approved

amount for covered healthcare costs. Then your Medicare Supplement plan pays its share.

With four plan options, its easy to find the plan that is right for you.

Plan A Rates as low as $169 a month

A plan with basic coverage

Plan A provides basic coverage for those with fewer hospital and physician expenses.

Plan F Rates as low as $211 a month

Our most popular plan

Plan F provides 100% coverage for Medicare covered services. That means no copayments, coinsurance, or deductibles.

High Deductible Plan F Rates as low as $90 a month

Like Plan F, but with a high deductible and a lower monthly rate

A nice fit if you prefer a high deductible health plan. You can use funds in an existing HSA (Health Savings Account) to pay for medical expenses applied to your deductible.

Plan N Rates as low as $167 a month

Coverage with a copay

100% coverage on all Medicare-covered inpatient hospital services. After youve met your Part B deductible, you pay a copay for office visits and emergency room visits.

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

Questions? Were here to help. 855-339-4106 premera.com

Plan details Plan ABasic coverage

Plan FOur most popular plan

Monthly rates (save $5 per month on rates listed below by enrolling in our Automatic Funds Transfer [AFT] program)

Monthly rate $169 $211

Plan summary Your costs: Your costs:

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

Deductibles Hospital - Part A: $1,316Medical - Part B: $183 $0

Office visit $0 after Part B deductible $0

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

Skilled nursing facility$0/day (days 120)

$164.50/day (days 21100)All costs (days 101+)

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

Outpatient hospital care $0 after Part B deductible $0

Ambulance $0 after Part B deductible $0

Emergency care $0 after Part B deductible $0

Urgent care $0 after Part B deductible $0

Durable medical equipment $0 after Part B deductible $0

Outpatient lab/x-rays $0 after Part B deductible $0

Part B excess charges (above Medicare approved amounts)

Not covered $0

Home health care $0 $0

Hospice $0 $0

Foreign travel coverage (not covered by Medicare)

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

Remainder of charges (per calendar year) Not covered

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

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

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospi-tal and have not received skilled care in any other facility for 60 days in a row.

DISCOVER a Medicare Supplement plan thats right for you

Plan details High Deductible Plan FHigh deductible, lower cost

Plan NCoverage with a copay

Monthly rates (save $5 per month on rates listed below by enrolling in our Automatic Funds Transfer [AFT] program)

Monthly rate $90 $167

Plan summary Your costs: Your costs:

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

Deductibles $2,200 annual plan deductible Medical - Part B: $183

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

Inpatient hospital care $0 after plan deductible $0

Skilled nursing facilityAfter plan deductible:$0/day (days 1100)All costs (days 101+)

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

Outpatient hospital care $0 after plan deductible $0 after Part B deductible

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

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

Urgent care $0 after plan deductible $0 after Part B deductible

Durable medical equipment $0 after plan deductible $0 after Part B deductible

Outpatient lab/x-rays $0 after plan deductible $0 after Part B deductible

Part B excess charges (above Medicare approved amounts)

$0 after plan deductible Not covered

Home health care $0 $0

Hospice $0 $0

Foreign travel coverage (not covered by Medicare)

First $250 in charges (per calendar year)

After plan deductible: You pay first $250 in charges You pay first $250 in charges

Remainder of charges (per calendar year)

After plan deductible: After the first $250 in charges, you pay 20%

and amounts over $50,000 lifetime max

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

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

Questions? Were here to help. 855-339-4106 premera.com

DISCOVER a Medicare Supplement plan thats right for you

Extra member benefits and services

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

24-Hour NurseLine**

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

Web toolsManage your health and policy online. Store and manage your health information online, and access health and fitness tracking tools at premera.com.

Premera Senior Discounts program**

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

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

Medicare Glossary

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

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

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

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

Questions? Were here to help. 855-339-4106 premera.com

Here are some other definitions to help you understand Medicare and Medicare Supplement benefits:

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

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

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

Copaya flat fee you pay at the time a service is rendered.

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

037397 (07-2016)

Discrimination is Against the Law

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

Premera: Provides free aids and services to people with

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

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

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

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

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

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

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

Getting Help in Other Languages

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

:(Arabic) .

Premera Blue Cross. . .

. (TTY: 800-842-5357) 1471-722-800

(Chinese):

Premera Blue Cross

800-722-1471 (TTY: 800-842-5357)

Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu dandaa. Guyyaawwan murteessaa taan beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu dandaa. Kaffaltii irraa bilisa haala taeen afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa. Franais (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermdiaire de Premera Blue Cross. Le prsent avis peut contenir des dates cls. Vous devrez peut-tre prendre des mesures par certains dlais pour maintenir votre couverture de sant ou d'aide avec les cots. Vous avez le droit d'obtenir cette information et de laide dans votre langue aucun cot. Appelez le 800-722-1471 (TTY: 800-842-5357). Kreyl ayisyen (Creole): Avi sila a gen Enfmasyon Enptan ladann. Avi sila a kapab genyen enfmasyon enptan konsnan aplikasyon w lan oswa konsnan kouvti asirans lan atrav Premera Blue Cross. Kapab genyen dat ki enptan nan avi sila a. Ou ka gen pou pran kk aksyon avan sten dat limit pou ka kenbe kouvti asirans sante w la oswa pou yo ka ede w avk depans yo. Se dwa w pou resevwa enfmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357). Deutsche (German): Diese Benachrichtigung enthlt wichtige Informationen. Diese Benachrichtigung enthlt unter Umstnden wichtige Informationen bezglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie knnten bis zu bestimmten Stichtagen handeln mssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357).

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800-722-1471 (TTY: 800-842-5357)

(Korean): . Premera Blue Cross . . . . 800-722-1471 (TTY: 800-842-5357) . (Lao): . Premera Blue Cross. . . . 800-722-1471 (TTY: 800-842-5357). (Khmer):

Premera Blue Cross

800-722-1471 (TTY: 800-842-5357)

(Punjabi): . Premera Blue Cross . . , , 800-722-1471 (TTY: 800-842-5357).

:(Farsi) .

. Premera Blue Cross .

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Enrolling is easy! You can:

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

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

Call toll free 855-339-4106 (TTY: 711) Monday Friday, 8 a.m. to 8 p.m. (7 days a week, 8 a.m. to 8 p.m., from October 1 through February 14)

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

021138 (01-2017)

Enroll onlineGo to premera.com

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

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

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association