Medical Plan Highlights

Individual Medicare Supplement plans for residents of AlaskaBHBMSAK (05-01-2017)

MEDICARE SUPPLEMENT

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

You can count on us

Premera Blue Cross Blue Shield of Alaska Medicare Supplement plans make it easy for you to get the care you need. With these plans, you can count on having:

• Freedom to use any doctor or hospital that accepts Medicare

• A plan that’s guaranteed renewable and portable

• Coverage that won’t be terminated if your health changes

• Nationwide coverage when you travel

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

Our Medicare Supplement plans are easy to use, and we make it simple for you to understand your benefits and costs. They cover the growing costs of Original Medicare and give you the freedom to see any doctor who accepts Medicare.

Premera 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 that’s right for you. And know that if you ever have questions about the best way to use your plan, we’re here to help.

PREMERA BLUE CROSS BLUE SHIELD OF ALASKA MEDICARE SUPPLEMENT PLANS HELP YOU ENJOY IT

A Medicare Supplement plan can help pay some of the healthcare costs that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles. Some Medicare Supplement plans also offer coverage for services that Original Medicare doesn’t 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.

Premera Medicare Supplement Plans

WITH FIVE PLAN OPTIONS, IT’S EASY TO FIND THE PLAN THAT IS RIGHT FOR YOU.

Rates as low as $137 a monthA plan with basic coveragePlan A provides coverage for those with fewer hospital and physician expenses.

Plan A

Rates as low as $129 a monthOur newest plan optionPlan G offers the same great benefits as Plan F. However, Plan G doesn’t cover the Medicare Part B deductible so you’ll pay that cost if you choose Plan G.

Plan G

Rates as low as $183 a monthOur most popular planPlan F provides 100% coverage for Medicare-covered services. That means no copayments, coinsurance, or deductibles.

Plan F

Rates as low as $133 a monthCoverage with a copay100% coverage on all Medicare-covered inpatient hospital services. After you’ve met your Part B deductible, you pay a copay for office visits and emergency room visits.

Plan N

Rates as low as $72 a monthLike Plan F, but with a high deductible and a lower montly rateA 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.

High Deductible Plan F

Policy form numbers: Plan A 021198 (06-2010), 021202 (06-2010) Plan F 021200 (06-2010), 021204 (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 hospital and have not received skilled care in any other facility for 60 days in a row.

Discover A MEDICARE SUPPLEMENT PLAN THAT’S RIGHT FOR YOU

Plan details Plan ABasic coveragePlan F

Our most popular plan

Monthly rates are $5 more if you choose not to enroll in our Automatic Funds Transfer (AFT) program

Monthly rate (age 65-69) $137 $183

Monthly rate (age 70-74) $167 $224

Monthly rate (age 75+) $208 $279

Plan summary Your costs: Your costs:

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

accepts Medicare

Deductibles Hospital - Part A: $1,364Medical - Part B: $185 $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 1–20)

$170.50/day (days 21–100)All costs (days 101+)

$0/day (days 1–100)All costs (days 101+)

Outpatient hospital care $0 after Part B deductible $0Ambulance $0 after Part B deductible $0Emergency care $0 after Part B deductible $0Urgent care $0 after Part B deductible $0Durable medical equipment $0 after Part B deductible $0Outpatient lab/x-rays $0 after Part B deductible $0Part B excess charges (above Medicare approved amounts) Not covered $0

Home health care $0 $0Hospice $0 $0Foreign 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: High Deductible Plan F (021201 (06-2010), 021205 (06-2010) Plan G 042193 (01-2018), 042194 (01-2018) Plan N 021199 (06-01-2010), 021203 (06-01-2010)

High Deductible Plan FHigh deductible, lower cost

Plan GOur newest option

Plan NCoverage with a copay

Monthly rates are $5 more if you choose not to enroll in our Automatic Funds Transfer (AFT) program

$72 Monthly rate (Age 65) $129Monthly rate (Age 66)

$136 $133

$89 Monthly rate (Age 67) $146Monthly rate (Age 68)

$155 $161

$111 Monthly rate (Age 69) $176Monthly rate (Age 70-74)

$185 $202Monthly rate (Age 75+)

$248Your costs: Your costs: Your costs:

Any doctor or hospital that accepts Medicare

Any doctor or hospital that accepts Medicare

Any doctor or hospital that accepts Medicare

$2,300 annual plan deductible Medical - Part B: $185 Medical - Part B: $185

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

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

After plan deductible:$0/day (days 1–100)All costs (days 101+)

After Part B deductible:$0/day (days 1–100)All costs (days 101+)

$0/day (days 1–100)All costs (days 101+)

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

$0 after plan deductible $0 after Part B deductible Not covered

$0 $0 $0$0 $0 $0

Foreign travel coverage (not covered by Medicare)

After plan deductible: You pay first $250 in charges 100% after Part B deductible You pay first $250 in charges

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 maximum

After the first $250 in charges, you pay 20% and amounts over

$50,000 lifetime maximum

Which Medicare Supplement plan is right for you?

Our Medicare Supplement plans build on the coverage you get from Parts A and B of Original Medicare, giving you complete coverage. To help you choose the Medicare Supplement plan that best meets your needs

and lifestyle, take a look at this overview that compares each plan we offer and shows you what’s covered. You may want to look back at some of your recent medical claims to see what your needs are.

As you consider your options, keep in mind:

• Plan A: If you don’t need to go to the doctor very often, Plan A is probably a good fit for you.

• Plan F: Covers the Part B deductible and excess charges, so this plan could make sense if you are seeking predictability of cost. No surprises!

• High deductible F: Designed with cost shares that help you keep monthly premiums low.

• Plans F, G, N, and high deductible F: These plans are good choices for anyone who travels abroad a lot, since these plans cover foreign travel emergencies.

• Plan G: Looks a lot like our popular Plan F, but you’ll keep your monthly premiums lower by covering the Part B deductible.

Plan BenefitsPlan A Pays

Plan F Pays

High Deductible F Pays

Plan G Pays

Plan N Pays

Blood (first 3 pints) X X X X X

Foreign travel emergency X X X X

Hospice care coinsurance/copays X X X X X

Parts A and B coinsurance/copays X X X X X

Part A deductible (per benefit period) X X X X

Part B deductible (once a year) X X

Part B excess charges X X X

Skilled nursing facility coinsurance for each day 21–100 of benefit period

X X X X

Extra member benefits and services

Customer serviceOur responsive customer service teams are right here in Washington, not thousands of miles away. We’re ready to help answer your plan and benefit questions, and we’re trained and equipped to help get the answers you need, when you need them. Call us at 855-339-4106.

Web toolsOur web tools make it easy for you to see your benefits and costs. Store and manage your health information online, and access health and fitness tracking tools at premera.com.

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.

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.

QUESTIONS? 855-339-4106 • premera.com

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

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

Deductible—the amount you pay for healthcare before Original Medicare begins to pay.

Cost shares—the amount you pay, such as copays and coinsurance.

Copay—the fixed amount you pay at the time of service for each healthcare visit.

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

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.

HERE ARE SOME OTHER DEFINITIONS TO HELP YOU UNDERSTAND MEDICARE AND MEDICARE SUPPLEMENT BENEFITS:

Medicare glossary

If you don’t understand something, just ask us. It’s our job to make things easy for you.

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.

Enrolling is easy! You can:Enroll onlineGo to premera.com

Enroll by mailReturn your paper application to:PO 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.

037398 (07-2016)

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 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 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). አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross Blue Shield of Alaska ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 800-508-4722 (TTY: 800-842-5357) ይደውሉ።

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េសចកត ីជូនដំណឹងេនះរបែហលជាមានព័ត៌មាន

យ៉ាងសំខាន់អំពីទរមង់ែបបបទ ឬការរ៉ាប់រងរបស់

អនកតាមរយៈ Premera Blue Cross Blue Shield of Alaska ។ របែហលជាមាន កាលបរេិចឆទសំខាន់េនៅកន ុងេសច

កត ីជូនដំណឹងេនះ។ អនករបែហលជារតវូការបេញចញ

សមតថភាព ដល់កំណត់ៃថងជាក់ចបាស់នានា េដើមបី

នឹងរកសាទុកការធានារ៉ាប់រងសុខភាពរបស់អនក ឬ

របាក់ជំនួយេចញៃថល។ អនកមានសិទធិទទួលព័ត៌មាន

េនះ និងជំនួយេនៅកន ុងភាសារបស់អនកេដាយមិនអ

សលុយេឡើយ។ សូមទូរស័ពទ 800-508-4722 (TTY: 800-842-5357)។

ਪੰਜਾਬੀ (Punjabi): ਇਸ ਨੋਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋਿਟਸ ਿਵਚ Premera Blue Cross Blue Shield of Alaska ਵਲ� ਤੁਹਾਡੀ ਕਵਰੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹੱਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇਕਰ ਤੁਸੀ ਜਸਹਤ ਕਵਰੇਜ ਿਰੱਖਣੀ ਹੋਵੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ਇਛੱੁਕ ਹੋ ਤਾਂ ਤੁਹਾਨੰੂ ਅੰਤਮ ਤਾਰੀਖ਼ ਤ� ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੱੁਕਣ ਦੀ ਲੋੜ ਹੋ ਸਕਦੀ ਹੈ ,ਤੁਹਾਨੰੂ ਮੁਫ਼ਤ ਿਵੱਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ੍ਰਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 800-508-4722 (TTY: 800-842-5357).

:(Farsi) فارسیممکن است اعالميه اين .ميباشد مھم اطالعات یوحا اعالميه اين

شما از ای بيمه پوشش يا و تقاضا فرم درباره مھم اطالعات حاوی به باشد. Premera Blue Cross Blue Shield of Alaska طريق برای است ممکن شما .نماييد توجه اعالميه اين در مھم ھای تاريخ بيمه تان يا کمک در پرداخت ھزينه ھای درمانی تان، پوشش حقظخاصی احتياج داشته انجام کارھای مشخصی برای ھای تاريخ به

زبان به را کمک و اطالعات اين که داريد را اين حق شما .باشيدنماييد. برای کسب اطالعات با شماره رايگان دريافت طور به خود

) 800-842- 5357تماس باشماره TTY(کاربران 800- 4722-508 تماس برقرار نماييد.

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross Blue Shield of Alaska. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-508-4722 (TTY: 800-842-5357). Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross Blue Shield of Alaska. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para 800-508-4722 (TTY: 800-842-5357).

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross Blue Shield of Alaska. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-508-4722 (TTY: 800-842-5357). Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross Blue Shield of Alaska. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-508-4722 (TTY: 800-842-5357). Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross Blue Shield of Alaska, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-508-4722 (TTY: 800-842-5357). Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través 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 médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-508-4722 (TTY: 800-842-5357).

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross Blue Shield of Alaska. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-508-4722 (TTY: 800-842-5357). ไทย (Thai): ประกาศนีมี้ข้อมลูสําคญั ประกาศนีอ้าจมีข้อมลูท่ีสําคญัเก่ียวกบัการการสมคัรหรือขอบเขตประกนัสขุภาพของคณุผา่น Premera Blue Cross Blue Shield of Alaska และอาจมีกําหนดการในประกาศนี ้คณุอาจจะต้องดําเนินการภายในกําหนดระยะเวลาท่ีแน่นอนเพ่ือจะรักษาการประกนัสขุภาพของคณุหรือการช่วยเหลือท่ีมีคา่ใช้จ่าย คณุมีสทิธิท่ีจะได้รับข้อมลูและความช่วยเหลือนีใ้นภาษาของคณุโดยไมมี่คา่ใช้จ่าย โทร 800-508-4722 (TTY: 800-842-5357) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross Blue Shield of Alaska. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-508-4722 (TTY: 800-842-5357). Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross Blue Shield of Alaska. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-508-4722 (TTY: 800-842-5357).

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

Call toll free 855-339-4106 (TTY: 711)021149 (11-10-2018)