Notice of changes in Medicare andMedicare Supplement Coverage

P.O. Box 327 Seattle, WA 98111

8460211

13

AK MF03

Alaska

November 2017

Dear Premera Blue Cross Blue Shield of Alaska Member:

Thank you for being a member of the Premera Blue Cross Blue Shield of Alaska MedicareSupplement plan.Medicare made changes to the level of coverage it provides, effective January 1, 2018. Youare receiving details of the changes in this letter. Please read below for a summary ofchanges Medicare is making for 2018.

Part A Hospital Deductible will change from $1,316 to $1,340 Part A Hospital Copay, days 61-90 will change from $329 to $335 Part A Hospital Copay, day 91 or after will change from $658 to $670 Part A Skilled Facility Copay, days 21-100 will change from $164.50 to $167.50 Part B Deductible will stay the same. It was $183 and it will be $183

You will find more details on the reverse side of this letter. It includes information aboutyour current health coverage and your rate effective January 1, 2018. If youd like to keepyour current Premera Medicare Supplement plan simply do nothing.

As a leader in healthcare coverage for Alaskans, we are committed to improving your life bymaking healthcare work better. If you have any questions about your Premera MedicareSupplement plan, please call us at 800-508-4722 or TDD for the hearing-impaired800-842-5357. You can also visit us online at www.premera.com.

We look forward to serving you in the year to come.

Sincerely,Your Premera Blue Cross Blue Shield of Alaska Medicare Supplement Plan Team

Over>

019559 (11-2017)

AK019559CF (09-2016) www.premera.com An Independent Licensee of theBlue Cross Blue Shield Association

AK MF03

Plan FNotice of changes in Medicare and your Medicare supplement coverage. The following chart briefly describes themodifications to Medicare and to your Medicare supplement coverage.

SERVICE MEDICARE YOU

Inpatient Hospital Deductible first 60 days

per benefit period

first 60 days per benefit period

Inpatient Hospital Copayment day day

Lifetime Reserve (60 additional days) day day

Post-hospital Skilled Nursing Facility Copayment

First 20 days All approved amounts

All approved amounts

21st thru 100th day All but All but

101st day and after $0 $0

Part B Deductible

$0 $0

$1,316 $1,340

$329 a day

$658 a day

$0

Up to

$164.50 a day

$0

First $183 ofPart B Medi-care-approvedamounts

$335 a day

$670 a day

$0

Up to

$167.50 a day

$0

First $183 ofPart B Medi-care-approvedamounts

$0 $0

$0

$0

$0

$0

All Costs

$0

$0

$0

$0

$0

All Costs

$0

Plan F

In 2017,MedicarePaid

In 2018,MedicareWill Pay

In 2017,Plan FPaid

In 2018,Plan FWill Pay

In 2017,You Paid

In 2018,You WillPay

All but $1,316 All but $1,340

All but $329 a All but $335 a

All but $658 a All but $670 a

$164.50 a day $167.50 a day

Plan F Rates Effective January 1, 2018We can only change your subscription charges if we change them for all plans like yours in this state.

You will see that you get a discount of $5 per month if you enroll in our Automatic Funds Transfer (AFT) program.If you choose this option, you will no longer send us a check each month. Instead, one months subscription chargeswill be withdrawn from your bank account automatically each month.

MONTHLY SUBSCRIPTION CHARGES PER PERSON AFT Payers Monthly Bill Payers

2017 Rate$247

2018 Rate

$247

2017 Rate$252

2018 Rate

$252Plan F

If you have any questions about your plan, please call us at 800-508-4722.

Please call Premera Customer Service at 800-508-4722 or TDD for the hearing-impaired800-842-5357 if we can help you with your healthcare coverage.

To obtain a copy of our Notice of Privacy Practices, please visit us at premera.com for anelectronic copy. For a paper copy, please contact us as listed below:

Premera Blue CrossMS 111 PO Box 327Seattle, WA 98111-0327800-427-7272

Discrimination is Against the Law Premera Blue Cross Blue Shield of Alaska 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, sex, gender identity, or sexual orientation. 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.

037398 (11-15-2017)

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 Blue Shield of Alaska. 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 800-508-4722 (TTY: 800-842-5357).

(Amharic): Premera Blue Cross Blue Shield of Alaska 800-508-4722 (TTY: 800-842-5357)

:(Arabic) .

.Premera Blue Cross Blue Shield of Alaska . . .

800-508-4722 (TTY: 800-842-5357)

(Chinese):

Premera Blue Cross Blue Shield of Alaska

800-508-4722 (TTY: 800-842-5357)

http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp:AppealsDepartmentInquiries@Premera.com

Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross Blue Shield of Alaska 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 800-508-4722 (TTY: 800-842-5357) tii bilbilaa.

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Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross Blue Shield of Alaska. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-508-4722 (TTY: 800-842-5357).

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Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso pu contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross Blue Shield of Alaska. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-508-4722 (TTY: 800-842-5357).

(Japanese):

Premera Blue Cross Blue Shield of Alaska

800508-4722 (TTY: 800-842-5357)

(Korean): . Premera Blue Cross Blue Shield of Alaska . . . . 800-508-4722 (TTY: 800-842-5357) .

(Lao): . Premera Blue Cross Blue Shield of Alaska. . . . 800-508-4722 (TTY: 800-842-5357).

(Khmer):

Premera Blue Cross Blue Shield of Alaska

800-508-4722 (TTY: 800-842-5357)

.

(Punjabi): . Premera Blue Cross Blue Shield of Alaska . . , ,800-508-4722 (TTY: 800-842-5357).

:(Farsi)

. Premera Blue Cross Blue Shield of Alaska.

.

. . ) 800-508-4722 TTY 800-842-5357)

Polski (Polish):To ogoszenie moe zawiera wane informacje. To ogoszenie moe zawiera wane informacje odnonie Pastwa wniosku lub zakresu wiadcze poprzez Premera Blue Cross Blue Shield of Alaska. Prosimy zwrcic uwag na kluczowe daty, ktre mog byzawarte w tym ogoszeniu aby nie przekroczy terminw w przypadku utrzymania polisy ubezpieczeniowej lub pomocy zwizanej z kosztami. Macie Pastwo prawo do bezpatnej informacji we wasnym jzyku. Zadzwocie pod 800-508-4722 (TTY: 800-842-5357).

Portugus (Portuguese): Este aviso contm informaes importantes. Este aviso poder conter informaes importantes a respeito de sua aplicao ou cobertura por meio do Premera Blue Cross Blue Shield of Alaska. Podero existir datas importantes neste aviso. Talvez seja necessrio que voc tome providncias dentro de determinados prazos para manter sua cobertura de sade ou ajuda de custos. Voc tem o direito de obter esta informao e ajuda em seu idioma e sem custos. Ligue para 800-508-4722 (TTY: 800-842-5357).

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P (Russian): . Premera Blue Cross Blue Shield of Alaska. . , , . . 800-508-4722 (TTY: 800-842-5357).

Faasamoa (Samoan): Atonu ua iai i lenei faasilasilaga ni faamatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei faasilasilaga o se fesoasoani e faamatala atili i ai i le tulaga o le polokalame, Premera Blue Cross Blue Shield of Alaska, ua e tau fia maua atu i ai. Faamolemole, ia e iloilo faalelei i aso faapitoa oloo iai i lenei faasilasilaga taua. Masalo o lea iai ni feau e tatau ona e faia ao lei aulia le aso ua taua i lenei faasilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo oloo e iai i ai. Oloo iai iate oe le aia tatau e maua atu i lenei faasilasilaga ma lenei famatalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-508-4722 (TTY: 800-842-5357).

Espaol (Spanish):Este Aviso contiene informacin importante. Es posible que este aviso contenga informacin importante acerca de su solicitud o cobertura a travs de Premera Blue Cross Blue Shield of Alaska. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura mdica o ayuda con los costos. Usted tiene derecho a recibir esta informacin y ayuda en su idioma sin costo alguno. Llame al 800-508-4722 (TTY: 800-842-5357).

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(Thai): Premera Blue Cross Blue Shield of Alaska 800-508-4722 (TTY: 800-842-5357)

(Ukrainian): . Premera Blue Cross Blue Shield of Alaska. , . , , . . 800-508-4722 (TTY: 800-842-5357).

Ting Vit (Vietnamese): Thng bo ny cung cp thng tin quan trng. Thng bo ny c thng tin quan trng v n xin tham gia hoc hp ng bo him ca qu v qua chng trnh Premera Blue Cross Blue Shield of Alaska. Xin xem ngy quan trng trong thng bo ny. Qu v c th phi thc hin theo thng bo ng trong thi hn duy tr bo him sc khe hoc c tr gip thm v chi ph. Qu v c quyn c bit thng tin ny v c trgip bng ngn ng ca mnh min ph. Xin gi s800-508-4722 (TTY: 800-842-5357).