carefirst medplus plan options 2020 - northern va · period ends when you haven’t received any...

CareFirst MedPlus Plan Options 2020

Medicare Supplement Insurance Coverage

NORTHERN VIRGINIA

800-275-3802 ■ www.carefirst.com/medigap 3

Why Choose CareFirst MedPlus?CareFirst MedPlus plans—our Medicare Supplement plans—cover most of the costs not covered by Original Medicare. Protect yourself with a CareFirst MedPlus1 plan.

Power of CareFirst BlueCross BlueShield CareFirst BlueCross BlueShield—the name you’ve known and trusted for over 80 years—is here to help you take on retirement. CareFirst MedPlus2 plans give you secure and stable coverage for today and whatever comes next.

Visit any doctor, any hospitalMore than 90% of primary care physicians in the U.S. accept Medicare.3 You have the freedom to visit any doctor or hospital that accepts Medicare.4

Plans to meet your budgetWe offer a selection of plans at competitive rates and multiple member discounts are available on all seven MedPlus plans.

Travel stress freeTake that next adventure knowing you are covered whether traveling within the U.S. or abroad.

Exclusive member dealsFree gym membership along with discounts on hearing aids, eyewear, meal services, travel and more.

1 CareFirst MedPlus plans are only available to individuals residing east of State Route 123 in Northern Virginia.2 CareFirstBlueCrossBlueShieldandCareFirstMedPlusareaffiliatedentities.3 www.kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/accessedonJuly11,2018.4 StandardwithallMedicareSupplementplans.

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Original Medicare does not cover everything and leaves you with what is called a “coverage gap.” Without a Medicare Supplement plan, it’s up to you to pay all the health care costs that fall into that gap—including Medicare deductibles, copays, and even 20% of all medical and hospital costs. CareFirst MedPlus plans fill those gaps. With seven plans to choose from, we have a plan to meet your needs.

Power of CareFirst MedPlusCareFirst MedPlus plans are backed by CareFirst BlueCross BlueShield. We give

you stability and security that comes with:

■■ National affiliation. Your card is recognized across the country.

■■ Local company. We live and work in your community and are proud to provide resources and volunteer hours to strengthen the people we serve.

■■ Trust. Awarded as one of the most ethical companies in the world for seven years in a row.

Visit any doctor, any hospitalEach of our seven plans gives you the freedom to visit any doctor—including

specialists—or hospital that accepts Medicare. No referrals needed. You have access to more than 50 local community hospitals and large hospital systems in the Washington metro area.

Free 24/7 nurse advice line. If you are unable to reach your doctor or need help after hours, FirstHelp

registered nurses are available to take your call and provide assistance.

Plans to meet your budgetWe offer a selection of plans at competitive rates and mutiple member

discounts are available on all seven MedPlus plans.

■■ Household discount. If you live with someone who is enrolled in a MedPlus plan, you will receive a 10% discount off the monthly premium when you enroll. The MedPlus member living with you will also get a 10% discount when they renew their MedPlus coverage. (Discount applies to two actively enrolled CareFirst MedPlus members.)

■■ Discount for annual one-time payment option or automatic monthly bank withdrawal option. Pay your full annual premium in one payment and you save $24 OR sign up for monthly autopay and reduce your monthly premium by $2 a month.

Travel stress freeWhen you travel within the U.S., your CareFirst MedPlus card is accepted

anywhere Medicare is accepted. Most of our plans also cover emergency care for when you are traveling outside the U.S.

“World’sMostEthicalCompanies”and“Ethisphere”namesandmarksareregisteredtrademarksofEthisphereLLC.


Exclusive member deals SilverSneakers® is a fitness program for seniors that is included at no additional charge. MedPlus members have access to:

■■ 16,000+ fitness locations1 across the country

■■ Exercise classes2 led by trained instructors

■■ Walking tracks, tennis courts and pools1

In addition to the benefits of the SilverSneakers fitness program, members socialize and create a sense of community.

Access online education on SilverSneakers.com, watch workout videos on SilverSneakers On-Demand™ or download the SilverSneakers GO™ fitness app, for additional workout ideas.

Exercising is just one part of staying healthy. Blue365® is a wellness discount program that helps our members stay healthy and happy while saving money.3 Our wide range of discount offers include national brands such as:

In addition to ongoing deals, there are weekly featured deals for every aspect of your life—like fitness gear, eyewear, hearing aids, financial services, travel discounts and more.

Additional coverage options for membersWhy waste time shopping multiple carriers to complete your coverage? We make shopping simple. Add to your medical coverage with the following optional plans:

Dental and vision coverage. Trips to the dentist and eye

doctor can get expensive. Ease the worry and the cost with these optional plans through CareFirst BlueCross BlueShield, a private not-for-profit health service plan. CareFirst MedPlus and CareFirst BlueCross BlueShield are affiliated entities. Learn more about these plans on page 18.

1 Participatinglocations(“PL”)arenotownedoroperatedbyTivityHealth,Inc.oritsaffiliates.UseofPLfacilitiesandamenitiesislimitedtotermsandconditionsofPLbasicmembership.FacilitiesandamenitiesvarybyPL.

2 MembershipincludesSilverSneakersinstructor-ledgroupfitnessclasses.Somelocationsoffermembersadditionalclasses.Classesvarybylocation.

3 Blue365issponsoredbyCareFirstinpartnershipwiththeBlueCrossandBlueShieldAssociation.4 SilverScript(PDP)isaPrescriptionDrugPlanwithaMedicarecontractofferedbySilverScript®InsuranceCompany.EnrollmentinSilverScriptdependsoncontractrenewal.SilverScriptisanindependentcompanysolelyresponsiblefortheservicesitprovidesanddoesnotprovideBlueCrossBlueShieldproductsorservices.PrescriptiondrugcoverageisoptionalandisnotincludedinanyCareFirstMedPlusMedicareSupplementplan.

SilverSneakersisaregisteredtrademarkofTivityHealth,Inc.SilverSneakersOn-DemandandSilverSneakersGOaretrademarksofTivityHealth,Inc.©2019TivityHealth,Inc.Allrightsreserved.SilverSneakersisaproductownedbyTivityHealth,Inc.,anindependentcompanythatissolelyresponsiblefortheirproductsandprovidesservicestoCareFirstMedPlusmembers.TivityHealthisnotinsuranceanddoesnotsellBlueCrossorBlueShieldproducts.SilverSneakers,Blue365andFirstHelparenotbenefitsguaranteedthroughyourMedicareSupplementinsurancepolicy.Theyare,however,healthprogramoptionsmadeavailableoutsideofthePolicytoCareFirstMedPlusmembers.

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Table of ContentsWhy Choose CareFirst MedPlus? . . . . . . . . . . . . . . . . . . . . . . . .

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Plan OptionsUnderstanding Your Medicare Options 9Plan Options 11Plan Options Comparison Chart 14Comparison 15Health and Wellness Programs 16Dental and Vision 18

Outline of CoverageMedicare Supplement Outline of Coverage 23

Additional InformationOpen Enrollment/Guaranteed Issue Guidelines . . . . . . . . . .

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61CareFirst’s Privacy Practices 64Rights and Responsibilities 66

Apply TodayThree Ways to Apply 77MyAccount 78Medigap Application 79

Plan Options


Understanding Your Medicare OptionsMedicare, which consists of Part A (hospital) and Part B (medical) and is commonly referred to as Original Medicare, was never designed to cover all of your health care expenses. With Medicare alone, you could be responsible for thousands of dollars in copays and deductibles.

Purchasing additional insurance is an important decision. You have two main options—Medicare Supplement, also known as Medigap, and Medicare Advantage plans.*

Medicare Supplement plans are designed to supplement Original Medicare by paying for the health care costs—the gaps in coverage—that Original Medicare doesn’t pay, such as the costs below. Medicare will pay its share first and then your Medicare Supplement plan will pay its share.

Medicare Part AYou are responsible for the deductible of $1,408 for each benefit period.

Coverage includes your hospital stays and other medical facility costs including:

■■ Inpatient care in hospitals

■■ Skilled nursing facility care

■■ Hospice care

■■ Home health care

Medicare Part BYou are responsible for the yearly deductible of $198. After your

deductible is met, you typically pay 20% of the Medicare-approved amounts for the following:

■■ Most doctor services (including doctor services you receive while you’re hospitalized)

■■ Outpatient therapy

■■ Durable medical equipment

Medicare Supplement plans are:

Flexible■■ Select your own doctors and hospitals, as long

as they accept Medicare

■■ See specialists without referrals

■■ Have the same coverage when you’re traveling throughout the U.S.

Simple ■■ Pay your monthly premium and your out-of-

pocket costs, like copays and deductibles, are limited

■■ Know what you’re going to pay before you visit the doctor or receive care

An alternative to Original Medicare and a Medicare Supplement plan is Medicare Advantage (MA), also referred to as Medicare Part C. Rather than supplementing Medicare like a Medicare Supplement plan, MA plans provide all of your Part A (hospital) and Part B (medical) coverage. Some plans also include prescription drug (Medicare Part D) coverage.

MA plans often have restricted networks. This means individuals in an MA plan must receive care from that plan’s network of doctors and hospitals and referrals may be required to see a specialist. Coverage when you travel is limited to emergency care only. While these plans may have low monthly premiums, you may be required to pay deductibles, copays and/or coinsurance when you use services. Enrollment in an MA plan is restricted to certain times of the year, unless you have become eligible for Medicare for the first time.*YoucannotbeenrolledinbothaMedicareSupplementplanandaMedicareAdvantageplan.

Plan Options10

Original Medicare doesn’t cover it allIt’s important to pick a plan that works for your budget and your needs. The chart below shows the possible out-of-pocket costs of an individual staying in the hospital a full 150 consecutive days as an inpatient within the same benefit period.*

Hospital StayWith Original

Medicare Part A (Hospital) Only,

You Pay

With CareFirst MedPlus Plan G,

You Pay

Days 1-60 $1,408Part A deductible

$0

Days 61-90 $10,560$352 copay x 30 days

$0

Days 91-150** $42,240$704 copay x 60 days

$0

A 150-day hospitalization would cost you:

$54,208With Medicare Part A

OR $0With CareFirst Plan G

**Medicare Lifetime Reserve DaysMedicare provides coverage for at least 90 days of consecutive inpatient hospitalization after you’ve paid your Medicare deductibles and copays. You are limited to a total of 60 additional days of hospitalization coverage in your lifetime to be used if your initial inpatient hospitalization extends beyond 90 days. These 60 additional days are called lifetime reserve days.

With a Medicare Supplement plan, you would be covered for an additional 365 days after you use all of your lifetime reserve days.

*Abenefitperiodbeginsthedayyou’readmittedasaninpatientinahospitalorskillednursingfacility(SNF).Thebenefitperiodendswhenyouhaven’treceivedanyinpatienthospitalcare(orskilledcareinaSNF)for60daysinarow.IfyougointoahospitaloraSNFafteronebenefitperiodhasended,anewbenefitperiodbegins.Youmustpaytheinpatienthospitaldeductibleforeachbenefitperiod.There’snolimittothenumberofbenefitperiods.Dollaramountsshownarethe2020deductibles,copaymentandcoinsurance.TheseamountsmaychangeonJanuary 1,2021.


Plan OptionsHaving Original Medicare alone could leave you with gaps in coverage and cost you thousands of dollars in health care costs each year. Purchasing a Medicare Supplement plan will cover the gaps in your Medicare coverage. You can pick from any of the seven plans listed below. See the comparison chart on pages 14–15 to compare plan options.

MedPlus Plan G

Ourplanwiththemostcomprehensivecoverageandlowestout-of-pocketcosts

With this plan, after you meet your $198 Part B deductible, your medical copayments and coinsurance are covered 100% by your plan. When traveling in a foreign country,2 your emergency care is covered.

MedPlus High-Deductible Plan G

Ourplanwiththe lowestmonthlypremium

After you meet your $2,340 plan deductible and $198 Part B deductible, your hospital and medical copayments and coinsurance are covered 100% by your plan. When traveling in a foreign country,2 your emergency care is covered, as well as skilled nursing facility care coinsurance.

MedPlus Plan NThis plan covers your Part A deductible, but you are responsible for the $198 Medicare Part B deductible and a small copay for office and emergency room visits. When traveling in a foreign country,2 your emergency care is covered.

Balance Billing Protection—If you see a doctor who does not accept Medicare’s reimbursement as payment in full for services (some doctors charge up to 15% more than Medicare allows), Plan G and High-Deductible Plan G will cover these extra charges.

See detailed benefits and rates in the Outline of Coverage beginning on page 23.

1 MedicarePartAandPartBdeductiblesareestablishedbyMedicare.2 MedicareSupplementplanspayupto80%ofbilledchargesforMedicare-eligibleexpensesforemergencycarereceivedduringthefirst60consecutivedaysofeachtripoutsidetheUnitedStates.Theplanpaymentissubjecttoacalendaryeardeductibleof$250andalifetimemaximumbenefitof$50,000.

Plan Options12

MedPlus Plan MThis plan covers half of your Part A deductible—you will be responsible for $704. After you meet your annual $198 Part B deductible and Part A deductible, your hospital and medical copayments and coinsurance are covered 100% by your plan. When traveling in a foreign country,2 your emergency care is covered, as well as skilled nursing facility care coinsurance.

MedPlus Plan LWith this plan, you are responsible for 25% of your Part A deductible — $352. Your out-of-pocket expenses will not exceed $2,940 each year.

MedPlus Plan BThis plan covers all of your $1,408 Part A deductible. Once you meet your $198 Part B deductible, your hospital and medical copayments and coinsurance are covered 100% by your plan.

MedPlus Plan AAfter you meet your annual $198 Part B deductible and $1,408 Part A deductible, your hospital and medical copayments and coinsurance are covered 100% by your plan.

What is not covered?Medicare Supplement policies are designed to work hand-in-hand with the federal Medicare program. They are not intended to be classified as long-term care policies and do not pay for most custodial care. Medicare Supplement plans do not cover expenses for services and items excluded from coverage under Medicare, or expenses for services and items that would duplicate Medicare payments.

Prescription drug coverage, or Medicare Part D, is not included in any CareFirst MedPlus Medicare Supplement plan.

Coverage is available on a guaranteed issue basisYour acceptance into one of CareFirst’s seven Medicare Supplement plans is guaranteed with no review of your medical history if:

■■ You are within six months* of your Medicare Part B effective date (Open Enrollment)

■■ You are in a Guaranteed Issue Period (please refer to the Additional Information section located in the back of this book)

And—you automatically receive our lowest Level 1 premiums!

Thepoliciesmayhaveexclusions,limitationsortermsunderwhichthepolicymaybecontinuedinforceordiscontinued.Forcostsandcompletedetailsofthecoverage,callyourinsuranceagentorCareFirst.1MedicarePartAandPartBdeductiblesareestablishedbyMedicare.2MedicareSupplementplanspayupto80%ofbilledchargesforMedicare-eligibleexpensesforemergencycarereceivedduringthefirst60consecutivedaysofeachtripoutsidetheUnitedStates.Theplanpaymentissubjecttoacalendaryeardeductibleof$250andalifetimemaximumbenefitof$50,000.

If you were newly eligible for Medicare prior to January 1, 2020, you may have additional plan options to choose from. Call CareFirst to learn more.


Coverage is available on an underwritten basis If you are more than six months past your Medicare Part B effective date (Open Enrollment) and are NOT applying during a Guaranteed Issue Period, you will need to answer questions regarding your medical history on the enclosed application, VAMEDPLUSAPP (6.19). This assessment will determine your acceptance and the premium you will receive. By missing the six-month Open Enrollment you are at risk of receiving more expensive monthly premiums. Please refer to the Outline of Coverage in this book for current pricing.

You risk nothing by applying today and you’ll be under no further obligation if you’re not satisfied with the coverage described.

Switching plans ■■ If you’re switching your coverage, Medicare

will give you full credit for every dollar you’ve already spent toward your Medicare Part B deductible.

■■ You may be subject to a review of your medical history through medical underwriting if you are outside of your Open Enrollment or Guaranteed Issue Period.

We’re here to answer your questions If you have any questions about the plans described in this book, or if you’d like assistance, just call 410-356-8123 or 800-275-3802. You’ll receive courteous, knowledgeable assistance from one of our dedicated product consultants.

Important Notice: A Guide to Health Insurance for People with Medicare is available to you at no charge. The guide describes the Medicare program and the health insurance available to those with Medicare. If you are interested in receiving this free guide, visit www.medicare.gov/pubs/pdf/02110-medicare-medigap-guide.pdf to download a copy or call us at 410-356-8123 or 800-275-3802 to receive a printed guide.

*Insomestates,MedicareSupplementplansareavailabletodisabledindividualsunderage65whoareeligiblefor Medicare.

Plan Options14

Plan Options Comparison ChartWhat You Pay with Original Medicare

versus CareFirst MedPlus Plans

With Original Medicare

alone, You Pay

With MedPlus

Plan A You Pay

With MedPlus

Plan B You Pay

With MedPlus

Plan F You Pay

With MedPlus High-Deductible

Plan F* You Pay

Only applicants who are eligible for Medicare before January 1, 2020 may

purchase High-Deductible Plan F

Hospital Services (Part A)

Inpatient hospital deductible $1,408 $1,408 $0 $0

$0 after plan deductible

Hospital days 61-90 $352/day $0 $0 $0 $0 after plan deductible

Hospital days 91-150 (lifetime reserve) $704/day $0 $0 $0


365 days after hospital benefits stop All costs $0 $0 $0


Skilled nursing facility days 21-100 $176/day $176/day $176/day $0


Medical Expenses (Part B)

Medical expense deductible $198 $198 $198 $0


Medical expenses after deductible 20% 0% 0% 0%


Excess charges above Medicare-approved amounts (balance billing)

100% 100% 100% $0 $0 after plan deductible

Other Expenses

Foreign country emergency care (beginning the first 60 days of each trip outside the USA)

100% 100% 100%$250

deductible, then 20%***

$250 deductible after plan



What You Pay with Original Medicare versus CareFirst MedPlus Plans

With MedPlus

Plan G You Pay

With MedPlus High-Deductible

Plan G* You Pay

With MedPlusPlan L** You Pay

With MedPlus Plan M You Pay

With MedPlus Plan N

You Pay

Hospital Services (Part A)

Inpatient hospital deductible $0

$0 after plan deductible $352 $704 $0

Hospital days 61-90 $0 $0 after plan deductible $0 $0 $0

Hospital days 91-150 (lifetime reserve) $0


365 days after hospital benefits stop $0


Skilled nursing facility days 21-100 $0


Up to $44/day $0 $0

Medical Expenses (Part B)

Medical expense deductible $198


Medical expenses after deductible 0%

$0 after plan deductible 5% 0%

Office visit—up to $20

ER visit—up to $50

Excess charges above Medicare-approved amounts (balance billing)

0% $0 after plan deductible 100% 100% 100%

Other Expenses

Foreign country emergency care (beginning the first 60 days of each trip outside the USA)

$250 deductible,

then 20%***

$250 deductible, after plan


100%$250


$250 deductible,

then 20%***

Dollaramountsshownarethe2020deductibles,copaymentandcoinsurance.TheseamountsmaychangeonJanuary 1, 2021.*WithHigh-DeductiblePlanG,thereisanannualplandeductibleof$2,340.Afteryoumeetthedeductible,youpay $0. **WithPlanL,thereisanout-of-pocketlimitof$2,940.Afteryoumeettheout-of-pocketlimit,youpay $0.***Upto$50,000lifetimemaximum.

Comparison

Plan Options16

Health and Wellness ProgramsLooking to get active, have fun and make friends?Through SilverSneakers,1 CareFirst MedPlus gives our members a way to get healthy and have fun—at no additional cost. SilverSneakers works to improve your overall well-being, fitness, and strength and gives you the chance to socialize, make new friends and connect with your community.

CareFirst MedPlus and SilverSneakers offer you:

■■ Membership at more than 16,000 gyms and fitness locations2 in the United States

■■ Access to fitness equipment2

■■ Specially-designed, signature exercise classes for all fitness levels3

■■ Pools, tennis courts and walking tracks2

Can’t get to a fitness location? SilverSneakers also offers an at-home option for members who want to start working out, but can’t get to a fitness location.

Enrolling couldn’t be easier. You’ll be automatically enrolled in SilverSneakers once you become a CareFirst MedPlus member. Your SilverSneakers welcome postcard will be mailed to you.

1 SilverSneakersisaproductownedbyTivityHealth,Inc.,anindependentcompanythatissolelyresponsiblefortheirproductsandprovidesservicestoCareFirstMedPlusmembers.TivityHealthisnotinsuranceanddoesnotsellBlueCrossorBlueShieldproducts.SilverSneakersisnotabenefitguaranteedthroughyourMedicareSupplementinsurancePolicy.Itis,however,ahealthprogramoptionmadeavailableoutsideofthePolicytoCareFirstMedPlusmembers.

2Participatinglocations(“PL”)arenotownedoroperatedbyTivityHealth,Inc.oritsaffiliates.UseofPLfacilitiesandamenitiesislimitedtotermsandconditionsofPLbasicmembership.FacilitiesandamenitiesvarybyPL.

3MembershipincludesSilverSneakersinstructor-ledgroupfitnessclasses.Somelocationsoffermembersadditionalclasses.Classesvarybylocation.

SilverSneakersisaregisteredtrademarkofTivityHealth,Inc.SilverSneakersOn-Demand™andSilverSneakersGO™aretrademarksofTivityHealth,Inc.©2019TivityHealth,Inc.Allrightsreserved.


Interactive tools and resources Visit www.carefirst.com/livinghealthy to access health tools that are informative and easy to use.

■■ Personalized features that let you record your health goals, reminders and medical history on our secure server

■■ Healthy cooking videos and recipes divided by category, including low sodium, heart-healthy and diabetes-friendly options

■■ A library of articles about diseases, health conditions, wellness tips, tests and procedures

■■ A multimedia section with videos, podcasts and tutorials about a variety of health topics

■■ Preventive guidelines

■■ Information on nutrition, smoking cessation, stress, weight management and more

Save 30 to 60% on hearing aids from TruHearing along with other health and wellness discounts.

Exclusive member discountsBlue365 is an exciting program that offers exclusive health, wellness and personal deals that will keep you healthy and happy, every day of the year. Blue365 delivers great discounts from top national and local retailers on:

■■ Fitness gear

■■ Healthy eating

■■ Family activities

■■ Hotel and travel discounts

■■ Eldercare assistance and much more

Visit www.carefirst.com/wellnessdiscounts to learn more.

We’re here to answer your questions. If you have any questions about the plans described in this book, you can speak to one of our dedicated product consultants at 410-356-8123 or 800-275-3802.

TheBlue365programisnotofferedasaninducementtopurchaseapolicyofinsurancefromCareFirstBlueCrossBlueShield.CareFirstBlueCrossBlueShielddoesnotunderwritethisprogrambecauseitisnotaninsuranceproduct.NobenefitsarepaidbyCareFirstBlueCrossBlueShieldunderthisprogram.ThediscountprogramlistedaboveisnotguaranteedbyCareFirstBlueCrossBlueShieldorCareFirstMedPlusandmaybediscontinuedatanytime.

Plan Options18

Dental and VisionDental coverage (optional)Your smile says a lot about your overall health. That’s why good dental care is so important. Complete your health coverage with a dental plan from CareFirst BlueCross BlueShield or CareFirst BlueChoice, Inc. We offer three options:*

■■ Individual Select Dental HMO offers lower, predictable copayments for routine and major dental services such as preventive and diagnostic care, surgical extractions, root canal therapy and orthodontic treatment. Select from a network of more than 600 participating providers. There is no deductible to meet.

■■ Individual Select Preferred Dental offers 100% coverage for preventive and diagnostic dental care as well as a network of more than 5,000 participating providers. There is no deductible to meet.

■■ BlueDental Preferred offers the largest network with more than 5,000 providers in Maryland, Washington, D.C. and Virginia and access to 123,000 dental providers across the country. See any doctor—no referral needed. Enjoy no charge oral exams, cleanings and X-rays when you visit an in-network provider. BlueDental Preferred has no benefit waiting periods.

All dental plans are guaranteed acceptance and require no claim forms when you stay in-network. If you have questions or would like to apply for dental coverage, please contact one of our dental product consultants at 855-503-4862.

Note: The dental and vision plans referenced are not part of any CareFirst MedPlus Medicare Supplement policy. To receive coverage for dental and/or vision services, you must apply separately for these plans. You do not need to be enrolled in a CareFirst medical plan to purchase a dental plan; however, you do need to be enrolled in a CareFirst medical plan to purchase a vision plan. The plans are not offered as an inducement to purchase a Medicare Supplement policy from CareFirst.

*IndividualSelectDentalHMOisunderwrittenbyCareFirstBlueChoice,Inc.;IndividualSelectPreferredDentalisunderwrittenbyGroupHospitalizationandMedicalServices,Inc.;BlueDentalPreferredisunderwrittenbyGroup HospitalizationandMedicalServices,Inc.;CareFirstBlueCrossBlueShieldisthebusinessnameofGroupHospitalizationandMedicalServices,Inc.


Interested in learning more about dental and vision coverage?Give us a call at 855-503-4862—or complete and mail this Free Information Request Card.

BlueVision℠ (optional)For just $2 a month, protect your eyes with a separate vision plan from CareFirst BlueCross BlueShield, administered by Davis Vision, Inc.* Receive an annual eye exam with dilation at participating providers for a $10 copay at the time of service, plus discounts** of approximately 30% on eyeglass frames and lenses or contact lenses from certain providers.

Our vision plan is guaranteed acceptance and requires no claim forms when you stay in-network. If you have questions or would like to apply for vision coverage, please contact one of our product consultants at 410-356-8123 or 800-275-3802.

Locate a participating provider at www.carefirst.com or call Davis Vision at 800-783-5602.

Mail this card for free information

YES, please rush me more information about the plan(s) that I’ve checked below. I understand this information is free and I am under no obligation.

Dental Plan Options

Individual Select Dental HMO

■ BlueDental Preferred

Individual Select Preferred Dental

Vision Option

BlueVision℠

*DavisVisionisanindependentcompanythatprovidesadministrativeservicesforvisioncaretoCareFirstmembers.DavisVision is solely responsible for the servicesitprovides.**SomeprovidersinMarylandandVirginiamaynolongerprovidethesediscounts.

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Outline of Coverage

Outline of CoverageIncludes detailed benefit and rate information

Medicare Supplement Outline of CoverageMedicare Supplement Plans A, B, F, High-Deductible F,

G, High-Deductible G, L, M and N For individuals residing in Northern Virginia

The Medicare deductibles and copays listed in this Outline of Coverage reflect 2020 Medicare costs and are subject to change each year as we receive updated figures from the federal government. New Medicare deductibles and copays go into effect on January 1 of each year.

Offered by First Care, Inc. of Maryland (used in VA by: First Care, Inc.), d/b/a CareFirst MedPlus, 10455 Mill Run Circle, Owings Mills, Maryland 21117-5559.

VAMEDPLUSOOC (6.19)

Outline of Coverage24

CareFirst MedPlusMedicareSupplementOutlineofCoverage

■■ This chart shows the benefits included in each of the standard Medicare Supplement plans.

■■ Every company must make Plan A available.■■ Some plans may not be available in your state.■■ CareFirst MedPlus offers plans A, B, F,

High-Deductible F, G, High-Deductible G, L, M and N as shaded below.

■■ Only applicants who are eligible for Medicare before January 1, 2020 may purchase Plans F and High-Deductible Plan F.

Basic Benefits:Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B coinsurance or copayments.

Blood: First three pints of blood each year.

Hospice: Part A coinsurance.

BenefitsPlans available to all applicants

Medicare eligible before 1/1/2020 only

A B D G1 K L M N C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Medicare Part B coinsurance or copayment

✔ ✔ ✔ ✔ 50% 75% ✔ ✔■copays apply3

✔ ✔

Blood (first three pints) ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔Part A hospice care coinsurance or copayment

✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Skilled nursing facility coinsurance ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔Medicare Part A deductible ✔ ✔ ✔ ✔ 50% 75% 50% ✔ ✔ ✔Medicare Part B deductible ✔ ✔Medicare Part B excess charges ✔ ✔Foreign travel emergency (up to plan limits)

✔ ✔ ✔ ✔ ✔ ✔

Out-of-pocket limit in 20202 $5,8802 $2,9402

Note: ✔■means100%ofthebenefitispaid.1 PlansFandGalsohaveahighdeductibleoptionwhichrequirefirstpayingaplandeductibleof$2,340beforetheplanbeginstopay.Oncetheplandeductibleismet,theplanpays100%ofcoveredservicesfortherestofthecalendaryear.HighdeductiblePlanGdoesnotcovertheMedicarePartBdeductible.However,highdeductiblePlans FandGcountyourpaymentoftheMedicarePartBdeductibletowardmeetingtheplandeductible.

2 PlansKandLpay100%ofcoveredservicesfortherestofthecalendaryearonceyoumeettheout-of-pocketyearlylimit.3 PlanNpays100%ofthePartBcoinsurance,exceptforacopaymentofupto$20forsomeofficevisitsanduptoa$50copaymentforemergencyroomvisitsthatdonotresultinaninpatientadmission.


CareFirst MedPlusMedicare Supplement Outline of Coverage

Premium informationCareFirst MedPlus can only raise your premiums if we raise the premiums for all policies like yours in your geographical region of your state.

Under Medicare supplement policies A, B, F, High-Deductible F, N, G, High-Deductible G, L and M, which use attained age rating, premiums automatically increase as you get older. You can expect your premiums to increase each year due to changes in age. We reserve the right to adjust premiums on your renewal.

The rate increase will be effective on the first of the policy renewal month. The policy renewal month means the month in which the policy becomes effective and each subsequent anniversary of that month. If the change from one age to another occurs prior to the policy renewal month, the rate increase will not be effective until the first of the policy renewal month. You will be notified of any rate increase at least 45 days prior to the date that a premium increase becomes effective.

Only applicants who are eligible for Medicare before January 1, 2020 may purchase Plans F and High-Deductible Plan F.

DisclosuresUse this outline to compare benefits and premiums among policies.

This outline shows benefits and premiums of policies sold for effective dates on or after January 1, 2020. Policies sold for effective dates prior to January 1, 2020 have different benefits.

Read your policy very carefullyThis 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 policyIf you find that you are not satisfied with your policy, you may return it to:

First Care, Inc. of Maryland (used in VA by: First Care, Inc.) d/b/a CareFirst MedPlus Individual Market Division 10800 Red Run Boulevard, RRE-375 Owings Mills, MD 21117

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 replacementIf 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.

NoticeThis policy may not fully cover all of your medical costs. Neither CareFirst MedPlus nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult MedicareandYou for more details.

Complete answers are very importantWhen you fill out the application for your new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.


What Will My Premiums Be?Premiums are based on:■■ Your gender■■ Your age when coverage becomes effective■■ When you enrolled in Medicare Part B■■ Whether you are in a Guaranteed Issue Period■■ The plan you select■■ Your tobacco use (ONLY if you are applying

more than six months past your Medicare Part B effective date and are not applying during a Guaranteed Issue Period)

■■ A review of your medical history through medical underwriting (ONLY if you are applying more than six months past your Medicare Part B effective date and are not applying during a Guaranteed Issue Period)

■■ Your payment option—you’ll receive $2 off monthly or $24 annually if you:

Elect automated premium payments via bank withdrawal or credit card payment ORChoose to pay your premium annually

■■ If you reside with someone who is enrolled in a CareFirst MedPlus plan, then both of you can receive a 10% discount off your premium

■■ You can only apply for Plan F or High-Deductible Plan F if you are eligible for Medicare before January 1, 2020.

Please noteAre you applying within six months of your Medicare Part B Effective Date (Open Enrollment) or during a Guaranteed Issue Period?

■■ The Level 1 Rate applies and is dependent on the plan you select, your age and gender. You are not required to answer any health or tobacco use questions found in Section 4 of the application. The tobacco use and health screening questions will not be used in determining your rate.

Are you applying more than six months past your Medicare Part B Effective Date (Open Enrollment) and are not applying during a Guaranteed Issue Period?

■■ Your medical history will be reviewed (medical underwriting). If you pass medical underwriting, you will receive a Level 1, Level 2 or Level 3 Rate, depending on review of your medical history information. Your rate will also be based on the plan you select, your age, gender and tobacco use.


What Will My Premiums Be? (continued)You are eligible to receive the lowest preferred rate as long as you apply within six months of your Medicare Part B effective date (Open Enrollment) or during a Guaranteed Issue Period. Rates for individuals applying outside of these periods are based on the results of medical underwriting.

Pleasenote:Level2and3rateswillbehigherthanLevel1rates.

A Guaranteed Issue Period

If you apply within six months of your Medicare Part B effective date, or during a Guaranteed Issue Period, you will receive:

Level 1 Rate

Example:Mary is 67 years old. Her Medicare Part B effective date is February 1, 2020, as found on her red, white and blue Medicare identification card. She is applying for Medicare Supplement Plan G coverage on March 1, 2020, which is within six months of her Medicare Part B effective date. Because this is her Open Enrollment Period, Mary gets a Level 1 Rate of $135.43, and tobacco use and health screening questions are not used in determining her rate.

ARates Based on Tobacco Use

and Review of Medical History

If you apply over six months and less than 10 years past your Medicare Part B effective date, and are not applying during a Guaranteed Issue Period, you could receive:

Level 1 (only eligible for Non-Tobacco users)Level 2 Tobacco or Non-Tobacco RateLevel 3 Tobacco or Non-Tobacco Rate

Denial, based on review of medical history

ARates Based on Tobacco Use

and Review of Medical History

If you apply 10 years or more past your Medicare Part B effective date, and are not applying during a Guaranteed Issue Period, you could receive:

Level 2 Tobacco or Non-Tobacco RateLevel 3 Tobacco or Non-Tobacco Rate

Denial, based on review of medical history

Ratesdisplayedareforthe2020planyearandaresubjecttochange.Theratesinthisbookarespecificallyforindividuals residing in Northern Virginia.


CareFirst MedPlus: Level 1, Female RatesIf you are applying within six months of your Medicare Part B effective date (Open Enrollment) or during a Guaranteed Issue Period, the Level 1 Rate applies and is dependent on the plan you select, your age and gender. You are not required to answer any health or tobacco use questions found in Section 4 of the application. Therefore, tobacco use and health screening questions will not be used in determining your rate.

If you are applying between seven months and 10 years past your Medicare Part B effective date, then your Level 1 Rate eligibility will depend on tobacco status and health evaluation.

You can receive a 10% discount if you reside with someone who is also actively enrolled in a CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect the annual payment option. See Section 6 of your application.

Monthly Premium Rates Effective January 1, 2020

Plans available to all applicants Medicare eligible before 1/1/20 only

Plan A Plan B Plan G High-Ded G Plan L Plan M Plan N Plan FHigh-Ded

FUnder

65 $553.85 N/A N/A N/A N/A N/A N/A N/A N/A

65 $474.92 $132.36 $122.84 $25.09 $94.29 $144.46 $105.54 $152.25 $25.9566 $498.66 $138.97 $128.98 $26.34 $99.00 $151.68 $110.82 $159.86 $27.2567 $523.59 $145.92 $135.43 $27.66 $103.96 $159.27 $116.36 $167.85 $28.6168 $549.77 $153.22 $142.20 $29.04 $109.15 $167.23 $122.17 $176.24 $30.0469 $577.26 $160.88 $149.31 $30.49 $114.61 $175.59 $128.28 $185.06 $31.5470 $600.35 $167.32 $155.29 $31.71 $119.19 $182.62 $133.41 $192.46 $32.8171 $624.37 $174.01 $161.50 $32.98 $123.96 $189.92 $138.75 $200.16 $34.1272 $649.34 $180.97 $167.96 $34.30 $128.92 $197.52 $144.30 $208.16 $35.4873 $675.32 $188.21 $174.68 $35.67 $134.08 $205.42 $150.07 $216.49 $36.9074 $702.33 $195.74 $181.66 $37.10 $139.44 $213.64 $156.08 $225.15 $38.3875 $728.32 $202.98 $188.38 $38.47 $144.60 $221.54 $161.85 $233.48 $39.8076 $755.26 $210.49 $195.35 $39.89 $149.95 $229.74 $167.84 $242.12 $41.2777 $783.21 $218.28 $202.58 $41.37 $155.50 $238.24 $174.05 $251.08 $42.8078 $812.19 $226.35 $210.08 $42.90 $161.25 $247.05 $180.49 $260.37 $44.3879 $842.24 $234.73 $217.85 $44.49 $167.22 $256.19 $187.17 $270.00 $46.0280 $856.88 $238.81 $221.64 $45.26 $170.12 $260.65 $190.42 $274.69 $46.8281 $871.79 $242.96 $225.49 $46.05 $173.09 $265.18 $193.73 $279.47 $47.6482 $886.92 $247.18 $229.41 $46.85 $176.09 $269.79 $197.10 $284.32 $48.4783 $902.21 $251.44 $233.36 $47.66 $179.13 $274.44 $200.50 $289.23 $49.3084 $917.67 $255.75 $237.36 $48.47 $182.19 $279.14 $203.93 $294.18 $50.1585 $933.45 $260.15 $241.44 $49.31 $185.33 $283.94 $207.44 $299.24 $51.0186 $944.65 $263.27 $244.34 $49.90 $187.55 $287.35 $209.93 $302.83 $51.6287 $956.01 $266.44 $247.28 $50.50 $189.81 $290.80 $212.45 $306.47 $52.2488 $967.48 $269.63 $250.25 $51.10 $192.08 $294.29 $215.00 $310.15 $52.8789 $979.11 $272.87 $253.25 $51.72 $194.39 $297.83 $217.59 $313.88 $53.50

90 & Older $990.80 $276.13 $256.28 $52.34 $196.72 $301.39 $220.18 $317.63 $54.14

Ratesdisplayedareforthe2020planyearandaresubjecttochange.Theratesinthisbookarespecificallyforindividualsresiding in Northern Virginia.


CareFirst MedPlus: Level 1, Male RatesIf you are applying within six months of your Medicare Part B effective date (Open Enrollment) or during a Guaranteed Issue Period, the Level 1 Rate applies and is dependent on the plan you select, your age and gender. You are not required to answer any health or tobacco use questions found in Section 4 of the application. Therefore, tobacco use and health screening questions will not be used in determining your rate.

If you are applying between seven months and 10 years past your Medicare Part B effective date, then your Level 1 Rate eligibility will depend on tobacco status and health evaluation.





FUnder


65 $505.87 $140.98 $130.85 $26.72 $100.44 $153.88 $112.42 $162.17 $27.6466 $531.16 $148.03 $137.39 $28.06 $105.46 $161.57 $118.04 $170.28 $29.0367 $557.72 $155.43 $144.26 $29.46 $110.73 $169.65 $123.94 $178.79 $30.4868 $585.61 $163.21 $151.47 $30.93 $116.27 $178.13 $130.14 $187.73 $32.0069 $614.89 $171.37 $159.05 $32.48 $122.08 $187.04 $136.64 $197.12 $33.6070 $639.48 $178.22 $165.41 $33.78 $126.96 $194.52 $142.11 $205.00 $34.9471 $665.06 $185.35 $172.02 $35.13 $132.04 $202.30 $147.79 $213.20 $36.3472 $691.67 $192.76 $178.90 $36.53 $137.32 $210.39 $153.71 $221.73 $37.8073 $719.33 $200.47 $186.06 $38.00 $142.82 $218.81 $159.85 $230.60 $39.3174 $748.11 $208.49 $193.50 $39.52 $148.53 $227.56 $166.25 $239.82 $40.8875 $775.79 $216.21 $200.66 $40.98 $154.03 $235.98 $172.40 $248.70 $42.3976 $804.49 $224.21 $208.09 $42.49 $159.72 $244.71 $178.78 $257.90 $43.9677 $834.26 $232.50 $215.79 $44.07 $165.63 $253.77 $185.39 $267.44 $45.5978 $865.12 $241.11 $223.77 $45.70 $171.76 $263.16 $192.25 $277.34 $47.2779 $897.13 $250.03 $232.05 $47.39 $178.12 $272.89 $199.37 $287.60 $49.0280 $919.58 $256.28 $237.86 $48.57 $182.58 $279.72 $204.36 $294.80 $50.2581 $942.60 $262.70 $243.81 $49.79 $187.14 $286.72 $209.47 $302.17 $51.5182 $966.17 $269.27 $249.91 $51.03 $191.83 $293.89 $214.71 $309.73 $52.8083 $990.31 $276.00 $256.15 $52.31 $196.62 $301.24 $220.07 $317.47 $54.1284 $1,015.07 $282.89 $262.55 $53.62 $201.53 $308.77 $225.57 $325.41 $55.4785 $1,040.43 $289.96 $269.11 $54.96 $206.57 $316.48 $231.21 $333.54 $56.8586 $1,052.91 $293.44 $272.34 $55.62 $209.05 $320.28 $233.99 $337.54 $57.5487 $1,065.54 $296.96 $275.61 $56.28 $211.55 $324.12 $236.79 $341.59 $58.2388 $1,078.33 $300.53 $278.92 $56.96 $214.09 $328.01 $239.63 $345.69 $58.9389 $1,091.27 $304.13 $282.26 $57.64 $216.66 $331.95 $242.51 $349.83 $59.63

90 & Older $1,104.36 $307.78 $285.65 $58.33 $219.26 $335.93 $245.42 $354.03 $60.35



CareFirst MedPlus: Level 2, Non-Tobacco Female RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder


65 $712.37 $198.54 $184.26 $37.63 $141.44 $216.69 $158.31 $228.37 $38.9366 $743.01 $207.07 $192.18 $39.25 $147.52 $226.01 $165.12 $238.19 $40.6067 $774.92 $215.97 $200.44 $40.93 $153.85 $235.72 $172.21 $248.42 $42.3568 $797.17 $222.17 $206.19 $42.11 $158.27 $242.49 $177.15 $255.55 $43.5669 $808.17 $225.23 $209.04 $42.69 $160.45 $245.83 $179.60 $259.08 $44.1670 $810.48 $225.88 $209.64 $42.81 $160.91 $246.53 $180.11 $259.82 $44.2971 $811.68 $226.21 $209.95 $42.87 $161.15 $246.90 $180.38 $260.20 $44.3572 $818.17 $228.02 $211.63 $43.22 $162.44 $248.87 $181.82 $262.29 $44.7173 $823.89 $229.61 $213.10 $43.52 $163.58 $250.61 $183.09 $264.12 $45.0274 $835.77 $232.93 $216.18 $44.15 $165.94 $254.23 $185.73 $267.93 $45.6775 $844.85 $235.45 $218.52 $44.63 $167.74 $256.99 $187.75 $270.84 $46.1776 $876.10 $244.17 $226.61 $46.28 $173.94 $266.50 $194.69 $280.86 $47.8777 $908.52 $253.20 $234.99 $47.99 $180.38 $276.36 $201.90 $291.25 $49.6578 $942.14 $262.57 $243.69 $49.76 $187.05 $286.58 $209.37 $302.03 $51.4879 $976.99 $272.28 $252.71 $51.61 $193.97 $297.19 $217.11 $313.20 $53.3980 $993.98 $277.02 $257.10 $52.50 $197.34 $302.35 $220.89 $318.64 $54.3281 $1,011.27 $281.84 $261.57 $53.42 $200.78 $307.61 $224.73 $324.19 $55.2682 $1,028.82 $286.73 $266.11 $54.34 $204.26 $312.95 $228.63 $329.82 $56.2283 $1,046.56 $291.67 $270.70 $55.28 $207.79 $318.35 $232.57 $335.50 $57.1984 $1,064.49 $296.67 $275.34 $56.23 $211.35 $323.80 $236.56 $341.25 $58.1785 $1,082.80 $301.77 $280.07 $57.20 $214.98 $329.37 $240.63 $347.12 $59.1786 $1,095.79 $305.39 $283.43 $57.88 $217.56 $333.32 $243.51 $351.28 $59.8887 $1,108.97 $309.07 $286.84 $58.58 $220.18 $337.33 $246.44 $355.51 $60.6088 $1,122.28 $312.77 $290.28 $59.28 $222.82 $341.38 $249.40 $359.77 $61.3389 $1,135.77 $316.53 $293.78 $59.99 $225.50 $345.48 $252.40 $364.10 $62.06

90 & Older $1,149.33 $320.31 $297.28 $60.71 $228.19 $349.61 $255.41 $368.45 $62.81



CareFirst MedPlus: Level 2, Non-Tobacco Male RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder


65 $758.81 $211.48 $196.27 $40.08 $150.65 $230.82 $168.63 $243.25 $41.4666 $791.43 $220.57 $204.71 $41.80 $157.13 $240.74 $175.88 $253.71 $43.2567 $825.43 $230.04 $213.50 $43.60 $163.88 $251.08 $183.43 $264.61 $45.1168 $849.13 $236.65 $219.63 $44.85 $168.59 $258.29 $188.70 $272.21 $46.4069 $860.84 $239.91 $222.66 $45.47 $170.91 $261.85 $191.30 $275.97 $47.0470 $863.30 $240.60 $223.30 $45.60 $171.40 $262.60 $191.85 $276.75 $47.1871 $864.58 $240.95 $223.63 $45.67 $171.66 $262.99 $192.13 $277.16 $47.2572 $871.50 $242.88 $225.42 $46.03 $173.03 $265.10 $193.67 $279.38 $47.6273 $877.59 $244.58 $226.99 $46.36 $174.24 $266.95 $195.02 $281.33 $47.9674 $890.25 $248.11 $230.27 $47.02 $176.75 $270.80 $197.84 $285.39 $48.6575 $899.91 $250.80 $232.77 $47.53 $178.67 $273.74 $199.98 $288.49 $49.1876 $933.21 $260.08 $241.38 $49.29 $185.28 $283.87 $207.38 $299.16 $51.0077 $967.74 $269.70 $250.31 $51.12 $192.14 $294.37 $215.06 $310.23 $52.8878 $1,003.54 $279.68 $259.57 $53.01 $199.24 $305.26 $223.01 $321.71 $54.8479 $1,040.67 $290.03 $269.18 $54.97 $206.62 $316.56 $231.27 $333.61 $56.8780 $1,066.72 $297.29 $275.91 $56.35 $211.79 $324.48 $237.05 $341.96 $58.2981 $1,093.41 $304.73 $282.82 $57.76 $217.09 $332.60 $242.99 $350.52 $59.7582 $1,120.76 $312.35 $289.89 $59.20 $222.52 $340.92 $249.06 $359.29 $61.2483 $1,148.76 $320.16 $297.14 $60.68 $228.08 $349.44 $255.29 $368.27 $62.7784 $1,177.48 $328.16 $304.56 $62.20 $233.78 $358.17 $261.67 $377.47 $64.3485 $1,206.90 $336.36 $312.17 $63.75 $239.62 $367.12 $268.21 $386.90 $65.9586 $1,221.38 $340.39 $315.92 $64.51 $242.49 $371.52 $271.42 $391.54 $66.7487 $1,236.03 $344.48 $319.71 $65.29 $245.40 $375.98 $274.68 $396.24 $67.5488 $1,250.86 $348.61 $323.54 $66.07 $248.35 $380.49 $277.97 $401.00 $68.3589 $1,265.87 $352.79 $327.43 $66.87 $251.33 $385.06 $281.31 $405.81 $69.17

90 & Older $1,281.06 $357.02 $331.35 $67.67 $254.34 $389.68 $284.69 $410.68 $70.00



CareFirst MedPlus: Level 2, Tobacco Female RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder


65 $890.27 $248.10 $230.27 $47.03 $176.76 $270.81 $197.83 $285.41 $48.6566 $928.55 $258.77 $240.17 $49.05 $184.36 $282.46 $206.34 $297.68 $50.7467 $968.44 $269.89 $250.48 $51.16 $192.28 $294.59 $215.20 $310.47 $52.9268 $996.25 $277.64 $257.68 $52.63 $197.80 $303.05 $221.38 $319.39 $54.4469 $1,009.99 $281.47 $261.23 $53.35 $200.53 $307.23 $224.44 $323.79 $55.1970 $1,012.87 $282.27 $261.98 $53.50 $201.10 $308.11 $225.08 $324.72 $55.3571 $1,014.37 $282.69 $262.37 $53.58 $201.40 $308.57 $225.41 $325.20 $55.4372 $1,022.49 $284.95 $264.46 $54.01 $203.01 $311.03 $227.22 $327.80 $55.8773 $1,029.63 $286.94 $266.31 $54.39 $204.43 $313.21 $228.80 $330.09 $56.2674 $1,044.48 $291.08 $270.15 $55.17 $207.38 $317.73 $232.10 $334.85 $57.0875 $1,055.82 $294.24 $273.09 $55.77 $209.63 $321.17 $234.62 $338.49 $57.7076 $1,094.89 $305.13 $283.19 $57.84 $217.38 $333.06 $243.30 $351.01 $59.8377 $1,135.40 $316.42 $293.67 $59.98 $225.43 $345.38 $252.31 $364.00 $62.0478 $1,177.41 $328.12 $304.54 $62.20 $233.77 $358.16 $261.64 $377.46 $64.3479 $1,220.97 $340.26 $315.80 $64.50 $242.42 $371.41 $271.32 $391.43 $66.7280 $1,242.19 $346.18 $321.29 $65.62 $246.63 $377.87 $276.04 $398.23 $67.8881 $1,263.81 $352.20 $326.88 $66.76 $250.92 $384.44 $280.84 $405.16 $69.0682 $1,285.74 $358.32 $332.56 $67.92 $255.28 $391.12 $285.72 $412.20 $70.2683 $1,307.91 $364.49 $338.29 $69.09 $259.68 $397.86 $290.64 $419.30 $71.4784 $1,330.32 $370.74 $344.09 $70.27 $264.13 $404.68 $295.62 $426.49 $72.7085 $1,353.21 $377.12 $350.00 $71.48 $268.67 $411.64 $300.71 $433.82 $73.9586 $1,369.44 $381.64 $354.20 $72.34 $271.89 $416.57 $304.31 $439.03 $74.8387 $1,385.91 $386.23 $358.46 $73.21 $275.16 $421.58 $307.97 $444.31 $75.7388 $1,402.54 $390.86 $362.76 $74.09 $278.47 $426.64 $311.67 $449.64 $76.6489 $1,419.40 $395.56 $367.13 $74.98 $281.81 $431.77 $315.42 $455.04 $77.56

90 & Older $1,436.35 $400.29 $371.51 $75.87 $285.18 $436.93 $319.18 $460.48 $78.49



CareFirst MedPlus: Level 2, Tobacco Male RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder


65 $948.30 $264.27 $245.28 $50.09 $188.28 $288.47 $210.73 $304.01 $51.8266 $989.07 $275.64 $255.82 $52.25 $196.37 $300.87 $219.79 $317.09 $54.0567 $1,031.56 $287.48 $266.81 $54.49 $204.81 $313.79 $229.23 $330.71 $56.3768 $1,061.18 $295.73 $274.47 $56.06 $210.69 $322.80 $235.81 $340.20 $57.9969 $1,075.82 $299.81 $278.26 $56.83 $213.60 $327.26 $239.07 $344.89 $58.7970 $1,078.89 $300.67 $279.05 $56.99 $214.21 $328.19 $239.75 $345.88 $58.9671 $1,080.49 $301.11 $279.47 $57.08 $214.52 $328.68 $240.10 $346.39 $59.0472 $1,089.13 $303.52 $281.70 $57.53 $216.24 $331.31 $242.03 $349.16 $59.5273 $1,096.74 $305.64 $283.67 $57.94 $217.75 $333.62 $243.72 $351.60 $59.9374 $1,112.56 $310.05 $287.76 $58.77 $220.89 $338.43 $247.23 $356.67 $60.8075 $1,124.64 $313.42 $290.89 $59.41 $223.29 $342.11 $249.92 $360.55 $61.4676 $1,166.25 $325.01 $301.65 $61.61 $231.55 $354.77 $259.16 $373.89 $63.7377 $1,209.40 $337.04 $312.81 $63.89 $240.12 $367.89 $268.75 $387.72 $66.0978 $1,254.15 $349.51 $324.38 $66.25 $249.00 $381.51 $278.70 $402.07 $68.5379 $1,300.55 $362.44 $336.39 $68.70 $258.22 $395.62 $289.01 $416.94 $71.0780 $1,333.10 $371.51 $344.80 $70.42 $264.68 $405.52 $296.24 $427.38 $72.8581 $1,366.46 $380.81 $353.43 $72.18 $271.30 $415.67 $303.65 $438.07 $74.6782 $1,400.64 $390.34 $362.27 $73.99 $278.09 $426.07 $311.25 $449.03 $76.5483 $1,435.64 $400.09 $371.33 $75.84 $285.04 $436.71 $319.03 $460.25 $78.4584 $1,471.52 $410.09 $380.61 $77.73 $292.16 $447.63 $327.00 $471.75 $80.4185 $1,508.29 $420.34 $390.12 $79.68 $299.46 $458.81 $335.17 $483.54 $82.4286 $1,526.38 $425.38 $394.80 $80.63 $303.05 $464.32 $339.19 $489.34 $83.4187 $1,544.70 $430.48 $399.53 $81.60 $306.69 $469.89 $343.26 $495.21 $84.4188 $1,563.23 $435.65 $404.33 $82.58 $310.37 $475.53 $347.38 $501.15 $85.4289 $1,581.99 $440.87 $409.18 $83.57 $314.09 $481.23 $351.55 $507.17 $86.45

90 & Older $1,600.97 $446.16 $414.09 $84.57 $317.86 $487.00 $355.76 $513.25 $87.48



CareFirst MedPlus: Level 3, Non-Tobacco Female RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder


65 $949.83 $264.71 $245.68 $50.17 $188.58 $288.92 $211.08 $304.49 $51.9066 $987.35 $275.17 $255.38 $52.15 $196.03 $300.34 $219.42 $316.52 $53.9567 $1,021.01 $284.55 $264.09 $53.93 $202.71 $310.57 $226.90 $327.31 $55.7968 $1,044.57 $291.12 $270.19 $55.18 $207.39 $317.74 $232.13 $334.86 $57.0869 $1,067.94 $297.63 $276.23 $56.41 $212.03 $324.85 $237.32 $342.35 $58.3670 $1,080.64 $301.17 $279.51 $57.08 $214.55 $328.71 $240.15 $346.43 $59.0571 $1,092.64 $304.51 $282.62 $57.71 $216.93 $332.36 $242.81 $350.27 $59.7172 $1,103.88 $307.65 $285.53 $58.31 $219.17 $335.78 $245.31 $353.88 $60.3273 $1,114.27 $310.54 $288.21 $58.86 $221.23 $338.94 $247.62 $357.21 $60.8974 $1,137.77 $317.09 $294.29 $60.10 $225.89 $346.09 $252.84 $364.74 $62.1775 $1,165.30 $324.76 $301.41 $61.55 $231.36 $354.47 $258.96 $373.57 $63.6876 $1,208.42 $336.78 $312.57 $63.83 $239.92 $367.58 $268.54 $387.39 $66.0377 $1,253.13 $349.24 $324.13 $66.19 $248.80 $381.18 $278.48 $401.72 $68.4878 $1,299.50 $362.16 $336.12 $68.64 $258.00 $395.29 $288.78 $416.59 $71.0179 $1,347.58 $375.56 $348.56 $71.18 $267.55 $409.91 $299.47 $432.00 $73.6480 $1,371.00 $382.09 $354.62 $72.42 $272.20 $417.04 $304.67 $439.51 $74.9281 $1,394.86 $388.74 $360.79 $73.68 $276.94 $424.29 $309.97 $447.16 $76.2282 $1,419.07 $395.49 $367.05 $74.96 $281.74 $431.66 $315.35 $454.92 $77.5483 $1,443.54 $402.31 $373.38 $76.25 $286.60 $439.10 $320.79 $462.76 $78.8884 $1,468.27 $409.20 $379.78 $77.56 $291.51 $446.62 $326.29 $470.69 $80.2385 $1,493.52 $416.24 $386.31 $78.89 $296.53 $454.31 $331.90 $478.79 $81.6186 $1,511.44 $421.23 $390.94 $79.84 $300.08 $459.76 $335.88 $484.53 $82.5987 $1,529.62 $426.30 $395.65 $80.80 $303.69 $465.28 $339.92 $490.36 $83.5988 $1,547.97 $431.41 $400.39 $81.77 $307.34 $470.87 $344.00 $496.24 $84.5989 $1,566.58 $436.60 $405.21 $82.75 $311.03 $476.53 $348.14 $502.21 $85.61

90 & Older $1,585.28 $441.81 $410.04 $83.74 $314.74 $482.22 $352.29 $508.20 $86.63



CareFirst MedPlus: Level 3, Non-Tobacco Male RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder


65 $1,011.74 $281.97 $261.69 $53.44 $200.87 $307.76 $224.84 $324.34 $55.2966 $1,051.70 $293.10 $272.03 $55.55 $208.81 $319.91 $233.72 $337.15 $57.4767 $1,087.56 $303.10 $281.30 $57.45 $215.92 $330.82 $241.68 $348.64 $59.4368 $1,112.66 $310.09 $287.80 $58.77 $220.91 $338.45 $247.26 $356.69 $60.8069 $1,137.54 $317.03 $294.23 $60.09 $225.85 $346.02 $252.79 $364.67 $62.1670 $1,151.07 $320.80 $297.73 $60.80 $228.54 $350.14 $255.80 $369.01 $62.9071 $1,163.86 $324.36 $301.04 $61.48 $231.07 $354.03 $258.64 $373.11 $63.6072 $1,175.83 $327.70 $304.14 $62.11 $233.45 $357.67 $261.30 $376.94 $64.2573 $1,186.90 $330.78 $307.00 $62.69 $235.65 $361.04 $263.76 $380.49 $64.8674 $1,211.93 $337.76 $313.47 $64.02 $240.62 $368.65 $269.32 $388.52 $66.2375 $1,241.26 $345.93 $321.06 $65.56 $246.44 $377.57 $275.84 $397.92 $67.8376 $1,287.18 $358.73 $332.94 $67.99 $255.56 $391.54 $286.05 $412.64 $70.3477 $1,334.81 $372.01 $345.26 $70.51 $265.01 $406.03 $296.63 $427.91 $72.9478 $1,384.20 $385.77 $358.03 $73.12 $274.82 $421.05 $307.61 $443.74 $75.6479 $1,435.41 $400.04 $371.28 $75.82 $284.99 $436.63 $318.99 $460.16 $78.4480 $1,471.33 $410.05 $380.57 $77.72 $292.12 $447.56 $326.97 $471.67 $80.4081 $1,508.16 $420.32 $390.09 $79.66 $299.43 $458.76 $335.15 $483.48 $82.4182 $1,545.88 $430.83 $399.85 $81.66 $306.92 $470.23 $343.54 $495.57 $84.4783 $1,584.50 $441.59 $409.84 $83.70 $314.59 $481.98 $352.12 $507.95 $86.5884 $1,624.11 $452.63 $420.09 $85.79 $322.45 $494.03 $360.92 $520.65 $88.7585 $1,664.69 $463.94 $430.58 $87.93 $330.51 $506.37 $369.94 $533.66 $90.9786 $1,684.66 $469.51 $435.75 $88.99 $334.47 $512.45 $374.38 $540.06 $92.0687 $1,704.87 $475.14 $440.98 $90.05 $338.49 $518.59 $378.87 $546.54 $93.1688 $1,725.33 $480.84 $446.27 $91.13 $342.55 $524.82 $383.41 $553.10 $94.2889 $1,746.03 $486.61 $451.62 $92.23 $346.66 $531.11 $388.01 $559.73 $95.41

90 & Older $1,766.98 $492.45 $457.04 $93.33 $350.82 $537.49 $392.67 $566.45 $96.56



CareFirst MedPlus: Level 3, Tobacco Female RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder

65 $1,072.85 N/A N/A N/A N/A N/A N/A N/A N/A

65 $1,187.03 $330.80 $307.02 $62.70 $235.68 $361.09 $263.78 $380.55 $64.8666 $1,233.91 $343.87 $319.15 $65.18 $244.99 $375.35 $274.20 $395.58 $67.4367 $1,275.98 $355.59 $330.03 $67.40 $253.34 $388.15 $283.55 $409.06 $69.7368 $1,305.43 $363.80 $337.65 $68.96 $259.18 $397.10 $290.09 $418.50 $71.3369 $1,334.63 $371.94 $345.20 $70.50 $264.98 $405.98 $296.58 $427.87 $72.9370 $1,350.50 $376.36 $349.30 $71.34 $268.13 $410.81 $300.11 $432.95 $73.8071 $1,365.50 $380.54 $353.18 $72.13 $271.11 $415.38 $303.44 $437.76 $74.6272 $1,379.55 $384.46 $356.82 $72.87 $273.90 $419.65 $306.56 $442.27 $75.3873 $1,392.53 $388.08 $360.18 $73.56 $276.48 $423.60 $309.45 $446.43 $76.0974 $1,421.90 $396.26 $367.77 $75.11 $282.31 $432.53 $315.97 $455.85 $77.7075 $1,456.31 $405.85 $376.67 $76.93 $289.14 $443.00 $323.62 $466.88 $79.5876 $1,510.19 $420.86 $390.61 $79.78 $299.84 $459.39 $335.59 $484.15 $82.5277 $1,566.07 $436.44 $405.06 $82.73 $310.93 $476.39 $348.01 $502.06 $85.5878 $1,624.01 $452.58 $420.05 $85.79 $322.44 $494.01 $360.89 $520.64 $88.7479 $1,684.10 $469.33 $435.59 $88.96 $334.37 $512.29 $374.24 $539.90 $92.0380 $1,713.37 $477.49 $443.16 $90.51 $340.18 $521.20 $380.74 $549.29 $93.6381 $1,743.19 $485.80 $450.87 $92.08 $346.10 $530.27 $387.37 $558.85 $95.2682 $1,773.44 $494.23 $458.70 $93.68 $352.11 $539.47 $394.09 $568.55 $96.9183 $1,804.02 $502.75 $466.61 $95.30 $358.18 $548.77 $400.89 $578.35 $98.5884 $1,834.93 $511.36 $474.60 $96.93 $364.31 $558.17 $407.76 $588.26 $100.2785 $1,866.49 $520.16 $482.76 $98.60 $370.58 $567.78 $414.77 $598.38 $101.9986 $1,888.88 $526.40 $488.56 $99.78 $375.03 $574.59 $419.74 $605.55 $103.2287 $1,911.60 $532.73 $494.43 $100.98 $379.54 $581.50 $424.79 $612.84 $104.4688 $1,934.53 $539.12 $500.36 $102.19 $384.09 $588.47 $429.89 $620.19 $105.7189 $1,957.80 $545.60 $506.38 $103.42 $388.71 $595.55 $435.06 $627.65 $106.98

90 & Older $1,981.17 $552.12 $512.43 $104.65 $393.35 $602.66 $440.25 $635.14 $108.26



CareFirst MedPlus: Level 3, Tobacco Male RatesIf you are applying more than six months past your Medicare Part B effective date, and are NOT applying during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based on the plan you select, your age, gender and tobacco use.





FUnder

65 $1,109.81 N/A N/A N/A N/A N/A N/A N/A N/A

65 $1,264.40 $352.37 $327.03 $66.79 $251.04 $384.62 $280.97 $405.35 $69.0966 $1,314.34 $366.28 $339.95 $69.43 $260.95 $399.81 $292.07 $421.36 $71.8267 $1,359.15 $378.77 $351.54 $71.80 $269.85 $413.44 $302.03 $435.73 $74.2768 $1,390.51 $387.51 $359.65 $73.45 $276.08 $422.99 $309.00 $445.78 $75.9869 $1,421.61 $396.18 $367.70 $75.10 $282.25 $432.45 $315.91 $455.75 $77.6870 $1,438.52 $400.89 $372.07 $75.99 $285.61 $437.59 $319.67 $461.17 $78.6171 $1,454.50 $405.35 $376.21 $76.83 $288.78 $442.45 $323.22 $466.30 $79.4872 $1,469.46 $409.52 $380.07 $77.62 $291.75 $447.00 $326.54 $471.09 $80.3073 $1,483.30 $413.37 $383.65 $78.35 $294.50 $451.21 $329.62 $475.53 $81.0574 $1,514.58 $422.09 $391.74 $80.01 $300.71 $460.73 $336.57 $485.56 $82.7675 $1,551.23 $432.30 $401.22 $81.94 $307.99 $471.87 $344.71 $497.31 $84.7776 $1,608.62 $448.30 $416.07 $84.98 $319.38 $489.33 $357.47 $515.71 $87.9077 $1,668.14 $464.88 $431.46 $88.12 $331.20 $507.44 $370.69 $534.79 $91.1678 $1,729.86 $482.08 $447.43 $91.38 $343.45 $526.21 $384.41 $554.58 $94.5379 $1,793.87 $499.92 $463.98 $94.76 $356.16 $545.68 $398.63 $575.09 $98.0380 $1,838.76 $512.43 $475.59 $97.13 $365.08 $559.34 $408.61 $589.49 $100.4881 $1,884.78 $525.26 $487.50 $99.56 $374.21 $573.34 $418.83 $604.24 $102.9982 $1,931.92 $538.39 $499.69 $102.05 $383.57 $587.68 $429.31 $619.35 $105.5783 $1,980.19 $551.85 $512.17 $104.60 $393.15 $602.36 $440.03 $634.83 $108.2184 $2,029.68 $565.64 $524.97 $107.22 $402.98 $617.42 $451.03 $650.69 $110.9185 $2,080.41 $579.77 $538.09 $109.90 $413.05 $632.85 $462.30 $666.95 $113.6886 $2,105.36 $586.73 $544.55 $111.22 $418.01 $640.44 $467.85 $674.95 $115.0587 $2,130.62 $593.77 $551.08 $112.55 $423.02 $648.12 $473.46 $683.05 $116.4388 $2,156.18 $600.89 $557.69 $113.90 $428.10 $655.90 $479.14 $691.25 $117.8289 $2,182.05 $608.10 $564.38 $115.27 $433.23 $663.77 $484.89 $699.54 $119.24

90 & Older $2,208.23 $615.40 $571.16 $116.65 $438.43 $671.73 $490.71 $707.93 $120.67



Medicare Supplement: Plan AMedicarePartAhospitalservicesperbenefitperiod1

Services Medicare Pays Plan A Pays You Pay Hospitalization1

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $0 $1,408 (Part A Deductible)61st thru 90th day All but $352 a day $352 a day $091st day and after:■■ While using 60 lifetime

reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used:

■■ Additional 365 days $0 100% of Medicare-eligible Expenses $02

■■ Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care1

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 days All approved amounts $0 $021st thru 100th day All but $176 a day $0 Up to $176 a day101st day and after $0 $0 All costsBloodFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0Hospice CareYou 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

1Abenefitperiodbeginsonthefirstdayyoureceiveserviceasaninpatientinahospitalandendsafteryouhavebeenoutofthehospitalandhavenotreceivedskilledcareinanyotherfacilityfor60daysinarow.

2Notice:WhenyourMedicarePartAhospitalbenefitsareexhausted,theinsurerstandsintheplaceofMedicareandwillpaywhateveramountMedicarewouldhavepaidforuptoanadditional365daysasprovidedinthepolicy’s“CoreBenefits.”DuringthistimethehospitalisprohibitedfrombillingyouforthebalancebasedonanydifferencebetweenitsbilledchargesandtheamountMedicarewouldhavepaid.


Medicare Supplement: Plan AMedicarePartBmedicalservicespercalendaryear

Services Medicare Pays Plan A Pays You Pay Medical Expenses—In or Out of Hospital and Outpatient Hospital TreatmentSuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $198 of Medicare-approved amounts1 $0 $0

$198 (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

BloodFirst 3 pints $0 All costs $0Next $198 of Medicare-approved amounts1 $0 $0


Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory ServicesTests for diagnostic services 100% $0 $0

Medicare Parts A and BHome Health Care Medicare-approved services

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment■■ First $198 of Medicare-

approved amounts1 $0 $0$198

(Part B Deductible)

■■ Remainder of Medicare-approved amounts 80% 20% $0

1Onceyouhavebeenbilled$198ofMedicare-approvedamountsforcoveredservices(whicharenotedwithafootnote),yourPartBdeductiblewillhavebeenmetforthecalendaryear.


Medicare Supplement: Plan BMedicarePartAhospitalservicesperbenefitperiod1

Services Medicare Pays Plan B Pays You Pay Hospitalization1


First 60 days All but $1,408 $1,408 (Part A Deductible) $0

61st thru 90th day All but $352 a day $352 a day $091st day and after:■■ While using 60 lifetime






You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 days All approved amounts $0 $021st thru 100th day All but $176 a day $0 Up to $176 a day101st day and after $0 $0 All costsBloodFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0Hospice CareYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness







Medicare Supplement: Plan BMedicarePartBmedicalservicespercalendaryear

Services Medicare Pays Plan B Pays You Pay Medical Expenses—In or Out of Hospital and Outpatient Hospital TreatmentSuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts1 $0 $0



Part B Excess Charges(Above Medicare- approved amounts) $0 $0 All costs

BloodFirst 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts1 $0 $0




Medicare Parts A and BHome Health Care Medicare-approved services

Medically necessary skilled care services and medical supplies

100% $0 $0


approved amounts1 $0 $0$198

(Part B Deductible)




Medicare Supplement: Plan FMedicarePartAhospitalservicesperbenefitperiod1

Only applicants who are eligible for Medicare before January 1, 2020 may purchase Plan F and High-Deductible Plan F.

Services Medicare Pays Plan F Pays You Pay Hospitalization1









You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 days All approved amounts $0 $021st thru 100th day All but $176 a day Up to $176 a day $0101st day and after $0 $0 All costsBloodFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0Hospice CareYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness







Medicare Supplement: Plan FMedicarePartBmedicalservicespercalendaryearOnly applicants who are eligible for Medicare before January 1, 2020 may purchase Plan F and High-Deductible Plan F.

Services Medicare Pays Plan F Pays You Pay Medical Expenses—In or Out of Hospital and Outpatient Hospital TreatmentSuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $198 of Medicare-approved amounts1 $0

$198 (Part B Deductible) $0


Part B Excess Charges(Above Medicare- approved amounts) $0 100% $0

BloodFirst 3 pints $0 All costs $0Next $198 of Medicare-approved amounts1 $0




Medicare Parts A and BHome Health Care Medicare-approved services Medically necessary skilled care services and medical supplies

100% $0 $0


approved amounts1 $0$198

(Part B Deductible) $0


Other Benefits Not Covered By MedicareForeign Travel—Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each trip outside the USAFirst $250 each calendar year $0 $0 $250

Remainder of charges $080% to a lifetime

maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum


44 Outline of Coverage44

Medicare Supplement: High-Deductible Plan FMedicarePartAhospitalservicesperbenefitperiod1

Only applicants who are eligible for Medicare before January 1, 2020 may purchase Plan F and High-Deductible Plan F.

Services Medicare Pays

After you pay $2,340 deductible,2

High-Deductible Plan F Pays

In addition to $2,340 deductible,2

You Pay

Hospitalization1









You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 days All approved amounts $0 $021st thru 100th day All but $176 a day Up to $176 a day $0101st day and after $0 $0 All costsBloodFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0Hospice CareYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness





2 ThisHigh-DeductibleplanpaysthesamebenefitsasPlanFafteronehaspaidacalendaryear$2,340deductible.BenefitsfromtheHigh-DeductiblePlanFwillnotbeginuntilout-of-pocketexpensesare$2,340.Out-of-pocketexpensesforthisdeductibleareexpensesthatwouldordinarilybepaidbythepolicy.ThisincludestheMedicaredeductiblesforPartAandPartB,butdoesnotincludetheplan’sseparateforeigntravelemergencydeductible.



Medicare Supplement: High-Deductible Plan FMedicarePartBmedicalservicespercalendaryearOnly applicants who are eligible for Medicare before January 1, 2020 may purchase Plan F and High-Deductible Plan F.

Services Medicare PaysAfter you pay

$2,340 deductible,2 High-Deductible

Plan F Pays

In addition to $2,340 deductible,2

You Pay

Medical Expenses—In or Out of Hospital and Outpatient Hospital TreatmentSuch as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $198 of Medicare-approved amounts1 $0



Part B Excess Charges(Above Medicare- approved amounts) $0 100% $0

BloodFirst 3 pints $0 All costs $0Next $198 of Medicare-approved amounts1 $0




Medicare Parts A and BHome Health Care Medicare-approved services Medically necessary skilled care services and medical supplies 100% $0 $0


approved amounts1 $0$198

(Part B Deductible) $0


Other Benefits Not Covered By MedicareForeign Travel—Not Covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each trip outside the USAFirst $250 each calendar year $0 $0 $250

Remainder of charges $080% to a lifetime

maximum benefit of $50,000

20% and amounts over the $50,000 lifetime

maximum1Onceyouhavebeenbilled$198ofMedicare-approvedamountsforcoveredservices(whicharenotedwithafootnote),yourPartBdeductiblewillhavebeenmetforthecalendaryear.

2ThisHigh-DeductibleplanpaysthesamebenefitsasPlanFafteronehaspaidacalendaryear$2,340deductible.BenefitsfromtheHigh-DeductiblePlan

carefirst medplus plan options 2020 - northern va · period ends when you haven’t received any...

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