BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC · BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – Cover page: 1 of 2 Benefit Plans A, Select B,

To review the benefit details, please click your county below:

• Alachua, Bay, Bradford, Brevard, Charlotte, Citrus, Clay, Collier, Columbia, Duval, Escambia, Flagler, Hamilton, Hernando, Highlands, Hillsborough, Indian River, Lake, Lee, Leon, Manatee, Marion, Okaloosa, Orange, Osceola, Pasco, Pinellas, Polk, Putnam, Santa Rosa, Sarasota, Seminole, St. Johns, Sumter, Suwanee and Volusia counties

• Broward, Miami-Dade, Okeechobee, Palm Beach and St. Lucie counties

Outline of Medicare Supplement CoverageBenefit Plans A, Select B,Select D and Select E

BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – Cover page: 1 of 2 Benefit Plans A, Select B, Select D and Select E See Outlines of Coverage sections for details about ALL plans. These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A”. Some plans may not be available in your state. Basic Benefits: for Plans A – J: 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. Blood: First three pints of blood each year.

A Select B C Select D Select E F F* G H I J J*

Basic Benefits

Basic Benefits

Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits

Skilled Nursing Facility Coinsurance








Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part B Deductible

Part B Deductible

Part B Deductible

Part B Excess (100%)

Part B Excess (80%)



Foreign Travel Emergency








At-Home Recovery

At-HomeRecovery

At-HomeRecovery

At-Home Recovery

Preventive Care NOT covered by Medicare

Preventive CareNOT covered by Medicare

*Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same benefits as plans F and J after one has paid a calendar year ($1,860) deductible. Benefits from high deductible plans F and J will not begin until out-of-pocket expenses exceed ($1,860). Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. 63368-707 (A1)

BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – Cover page: 2

Basic Benefits for Plan K and L include similar services as plans A-J, but cost sharing for the basic benefits is at different levels.

2

** Plans K and L provide for different cost-sharing for items and services than Plans A – J.

K** L**Basic Benefits 100% of Part A Hospitalization Coinsurance plus coverage for 365

Days after Medicare Benefits End 50% Hospice cost-sharing 50% of Medicare-eligible expenses for the first three pints of blood 50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End 75% Hospice cost-sharing 75% of Medicare-eligible expenses for the first three pints of blood 75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

Skilled Nursing Coinsurance

50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance

Part A Deductible

50% Part A Deductible 75% Part A Deductible

Part B Deductible



At-Home Recovery

Preventive-Care Not covered by Medicare

$(4140) Out of Pocket Annual Limit *** $(2070) Out of Pocket Annual Limit ***

Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges. ***The out-of-pocket annual limit will increase each year for inflation. See Outlines of Coverage for details and exceptions. 63368-707 (A1)

3

PREMIUM INFORMATION Blue Cross and Blue Shield of Florida, Inc., can only raise your premium if we raise the premium for all contracts like yours in this State. NOTE: Advantage65 Select contracts include restricted network provisions. You must use providers who participate in a network program to receive full Medicare supplemental benefits. You have the right to purchase any contract offered by Blue Cross and Blue Shield of Florida, with or without restricted network provisions. Premium amounts are available for bi-monthly, quarterly, semi-annual or annual payment modes. For information, please call 1-800-926-6565. MONTHLY PREMIUMS

Age at

Enrollment CompCoverage

Plan A Advantage65

Select B Advantage65

Select D Advantage65

Select E 65 $105.80 $110.10 $125.90 $137.10

66-67 $111.30 $114.30 $130.70 $145.60

68-69 $121.70 $120.30 $138.00 $154.50

70-71 $138.70 $127.10 $147.00 $160.30

72-74 $147.40 $136.10 $158.40 $168.30

75-79 $155.60 $143.90 $171.10 $183.50

80+ $163.50 $146.30 $178.90 $191.30

63368-707 (A1)

4

DISCLOSURES

Use this Outline to compare benefits and premiums among policies. READ YOUR CONTRACT VERY CAREFULLY

This is only an Outline describing your contract’s most important features. The contract is your insurance contract. You must read the contract itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN CONTRACT

If you find that you are not satisfied with your contract, you may return it to Blue Cross and Blue Shield of Florida, Inc., Post Office Box 44160, Jacksonville FL 32231-4160. If you send the contract back to us within 30 days after you receive it, we will treat the contract as if it had never been issued and return all of your payments. CONTRACT REPLACEMENT

If you are replacing another health insurance contract, do NOT cancel it until you have actually received your new contract and are sure you want to keep it. NOTICE

• This contract may not fully cover all of your medical costs. • Blue Cross and Blue Shield of Florida, Inc., is not connected with Medicare. • This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult

“The Medicare and You Handbook” for more details. COMPLETE ANSWERS ARE VERY IMPORTANT Review the application carefully before you sign it. Be certain that all information has been properly recorded. RENEWABILITY This contract will stay in effect as long as you pay your premiums on time. Otherwise, this contract can be cancelled only if you have made a material misrepresentation or omission on your application. Blue Cross and Blue Shield of Florida, Inc., reserves the right to change the premium rate following a 45 day written notice to you. LIMITATIONS

This contract does not contain limitations or exclusions on coverage that are more restrictive than those of Medicare. 63368-707 (A1)

5

COMPCOVERAGE PLAN A MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: --While using 60 lifetime reserve days --Once lifetime reserve days are used: --Additional 365 days --Beyond the Additional 365 days

All but $992 All but $248 a day All but $496 a day $0 $0

$0 $248 a day $496 a day 100% of Medicare Eligible Expenses $0

$992 (Part A Deductible) $0 $0 $0** All Costs

SKILLED NURSING FACILITY CARE* 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 hospital First 20 days 21st thru 100th day 101st day and after

All approved amounts All but $124 a day $0

$0 $0 $0

$0 Up to $124 a day All costs

BLOOD First 3 pints Additional amounts

$0 100%

3 pints $0

$0 $0

HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services.

All but very limited coinsurance for outpatient drugs and inpatient respite care.

$0

Balance

**Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits”. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

6

COMPCOVERAGE PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, --First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

$0 Generally 80%

$0 Generally 20%

$131 (Part B Deductible) $0

Part B Excess Charges (Above Medicare Approved Amounts)

$0

$0

All Costs

BLOOD First 3 pints Next $131 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

$0 $0 80%

All Costs $0 20%

$0 $131 (Part B Deductible) $0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A and B

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES --Medically necessary skilled care services and medical supplies --Durable medical equipment First $131 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

100% $0 80%

$0 $0 20%


7

ADVANTAGE65 SELECT B MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY

PAYS PARTICIPATING PROVIDER

NON-

PARTICIPATING PROVIDER


NON-

PARTICIPATING

PROVIDER

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: --While using 60 lifetime reserve days --Once lifetime reserve days are used: --Additional 365 days --Beyond the Additional 365 days


$992 (Part A Deductible) $248 a day $496 a day 100% of MedicareEligible Expenses $0

$0 $0 $0 $0 $0

$0 $0 $0 $0** All Costs

$992 (Part A Deductible) $248 a day $496 a day All Costs All Costs

EMERGENCY ADMISSIONS

Same as any

other admission

Same as any

other admission

Same as admission to participating hospital

All Costs beyond lifetime maximum benefit



8

ADVANTAGE65 SELECT B MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (continued) * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER

SKILLED NURSING FACILITY CARE* 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 hospital First 20 days 21st thru 100th day 101st day and after


$0 $0 $0

$0 $0 $0




$0 100%

3 pints $0

3 pints $0

$0 $0

$0 $0



$0

$0

Balance

Balance

9

ADVANTAGE65 SELECT B MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies --First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

$0 Generally 80%

$0 Generally 20%

$0 $0


$131 (Part B Deductible) 20%


$0

$0

$0

All Costs

All Costs


$0 $0 80%

All Costs $0 20%

All Costs $0 20%



CLINICAL LABORATORY SERVICES –TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

$0

$0

10

ADVANTAGE65 SELECT B MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR (continued) *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER

OTHER MEDICAL EXPENSES For outpatient care received from other providers such as physical and speech therapy, diagnostic tests, durable medical equipment, --First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

$0 Generally 80%

$0 Generally 20%

$0 Generally 20%




$0

$0

$0

All Costs

All Costs

EMERGENCY CARE Physicians and other outpatient providers

Generally 80% of Medicare approved amounts after Part B deductible



Charges applied to Part B Deductible

Charges applied to Part B Deductible plus charges above Medicare approved amounts

11


MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER

HOME HEALTH CARE MEDICARE APPROVED SERVICES --Medically necessary skilled care services and medical supplies --Durable medical equipment -- First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

100% $0 80%

$0 $0 20%

$0 $0 20%



12

ADVANTAGE65 SELECT D MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER




$0 $0 $0 $0 $0

$0 $0 $0 $0** All Costs



Same as any

other admission

Same as any

other admission





13

ADVANTAGE65 SELECT D MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (continued) * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER



$0 Up to $124 a day $0

$0 Up to $124 a day $0

$0 $0 All costs

$0 $0 All costs


$0 100%

3 pints $0

3 pints $0

$0 $0

$0 $0



$0

$0

Balance

Balance

14

ADVANTAGE65 SELECT D MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING


$0 Generally 80%

$0 Generally 20%

$0 $0




$0

$0

$0

All Costs

All Costs


$0 $0 80%

All Costs $0 20%

All Costs $0 20%




100%

$0

$0

$0

$0

15

ADVANTAGE65 SELECT D MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR (continued) *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER


$0 Generally 80%

$0 Generally 20%

$0 Generally 20%




$0

$0

$0

All Costs

All Costs







16

ADVANTAGE65 SELECT D MEDICARE PARTS A & B *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER

HOME HEALTH CARE MEDICARE APPROVED SERVICES --Medically necessary skilled care services and medical supplies --Durable medical equipment -- First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts AT-HOME RECOVERY SERVICES— NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan --Benefit for each visit --Number of visits covered (must be received within 8 weeks of last Medicare approved visit) --Calendar year maximum

100% $0 80% $0 $0 $0

$0 $0 20% Actual charges to $40 a visit Up to the numberof Medicare approved visits, not to exceed 7 each week $1600


$0 $131 (Part B Deductible) $0 Balance Balance Balance


17

ADVANTAGE65 SELECT D OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA --first $250 each calendar year -- Remainder of Charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000


$250 20% and amounts over the $50,000 lifetime maximum


18

ADVANTAGE65 SELECT E MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER




$0 $0 $0 $0 $0

$0 $0 $0 $0** All Costs



Same as any

other admission

Same as any

other admission





19

ADVANTAGE65 SELECT E MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (continued) * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY



$0 Up to $124 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0



$0

Balance

20

ADVANTAGE65 SELECT E MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY

MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies --First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

$0 Generally 80%

$0 Generally 20%



$0

$0

All Costs


$0 $0 80%

All Costs $0 20%



100%

$0

$0

21

ADVANTAGE65 SELECT E MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR (continued) *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY


$0 Generally 80%

$0 Generally 20%



$0

$0

All Costs






100% $0 80%

$0 $0 20%


22

ADVANTAGE65 SELECT E OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY


$0 $0



*PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare -- First $120 each calendar year -- Additional charges

$0 $0

$120 $0

$0 All Costs

*Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

Benefits for Broward, Miami-Dade, Okeechobee, Palm Beach and St. Lucie counties begin here.

BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – Cover page: 1 of 2 Benefit Plans A, Select B, Select D and Select E See Outlines of Coverage sections for details about ALL plans. These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A”. Some plans may not be available in your state. Basic Benefits: for Plans A – J: 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. Blood: First three pints of blood each year.

A Select B C Select D Select E F F* G H I J J*

Basic Benefits

Basic Benefits

Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits









Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part B Deductible

Part B Deductible

Part B Deductible


Part B Excess (80%)











At-Home Recovery

At-HomeRecovery

At-HomeRecovery

At-Home Recovery

Preventive Care NOT covered by Medicare

Preventive CareNOT covered by Medicare

*Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same benefits as plans F and J after one has paid a calendar year ($1,860) deductible. Benefits from high deductible plans F and J will not begin until out-of-pocket expenses exceed ($1,860). Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. 63368-707 (A2)

BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – Cover page: 2

Basic Benefits for Plan K and L include similar services as plans A-J, but cost sharing for the basic benefits is at different levels.

2

** Plans K and L provide for different cost-sharing for items and services than Plans A – J.

K** L**Basic Benefits 100% of Part A Hospitalization Coinsurance plus coverage for 365

Days after Medicare Benefits End 50% Hospice cost-sharing 50% of Medicare-eligible expenses for the first three pints of blood 50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End 75% Hospice cost-sharing 75% of Medicare-eligible expenses for the first three pints of blood 75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

Skilled Nursing Coinsurance

50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance

Part A Deductible

50% Part A Deductible 75% Part A Deductible

Part B Deductible



At-Home Recovery

Preventive-Care Not covered by Medicare

$(4140) Out of Pocket Annual Limit *** $(2070) Out of Pocket Annual Limit ***

Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges. ***The out-of-pocket annual limit will increase each year for inflation. See Outlines of Coverage for details and exceptions. 63368-707 (A2)

3

PREMIUM INFORMATION Blue Cross and Blue Shield of Florida, Inc., can only raise your premium if we raise the premium for all contracts like yours in this State. NOTE: Advantage65 Select contracts include restricted network provisions. You must use providers who participate in a network program to receive full Medicare supplemental benefits. You have the right to purchase any contract offered by Blue Cross and Blue Shield of Florida, with or without restricted network provisions. Premium amounts are available for bi-monthly, quarterly, semi-annual or annual payment modes. For information, please call 1-800-926-6565. MONTHLY PREMIUMS

Age at

Enrollment CompCoverage

Plan A Advantage65

Select B Advantage65

Select D Advantage65

Select E 65 $149.00 $154.20 $169.70 $202.50

66-67 $155.20 $160.30 $176.00 $215.00

68-69 $169.10 $168.20 $186.40 $227.90

70-71 $195.80 $178.60 $198.70 $236.70

72-74 $214.20 $195.20 $218.40 $248.70

75-79 $227.00 $211.40 $239.50 $271.10

80+ $237.00 $215.60 $248.80 $282.20

63368-707 (A2)

4

DISCLOSURES

Use this Outline to compare benefits and premiums among policies. READ YOUR CONTRACT VERY CAREFULLY

This is only an Outline describing your contract’s most important features. The contract is your insurance contract. You must read the contract itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN CONTRACT

If you find that you are not satisfied with your contract, you may return it to Blue Cross and Blue Shield of Florida, Inc., Post Office Box 44160, Jacksonville FL 32231-4160. If you send the contract back to us within 30 days after you receive it, we will treat the contract as if it had never been issued and return all of your payments.

CONTRACT REPLACEMENT

If you are replacing another health insurance contract, do NOT cancel it until you have actually received your new contract and are sure you want to keep it. NOTICE

• This contract may not fully cover all of your medical costs. • Blue Cross and Blue Shield of Florida, Inc., is not connected with Medicare. • This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult “The

Medicare and You Handbook” for more details. COMPLETE ANSWERS ARE VERY IMPORTANT Review the application carefully before you sign it. Be certain that all information has been properly recorded. RENEWABILITY This contract will stay in effect as long as you pay your premiums on time. Otherwise, this contract can be cancelled only if you have made a material misrepresentation or omission on your application. Blue Cross and Blue Shield of Florida, Inc., reserves the right to change the premium rate following a 45 day written notice to you. LIMITATIONS

This contract does not contain limitations or exclusions on coverage that are more restrictive than those of Medicare. 63368-707 (A2)

5

COMPCOVERAGE PLAN A MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: --While using 60 lifetime reserve days --Once lifetime reserve days are used: --Additional 365 days --Beyond the Additional 365 days


$0 $248 a day $496 a day 100% of Medicare Eligible Expenses $0

$992 (Part A Deductible) $0 $0 $0** All Costs



$0 $0 $0



$0 100%

3 pints $0

$0 $0



$0

Balance


6

COMPCOVERAGE PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, --First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

$0 Generally 80%

$0 Generally 20%



$0

$0

All Costs


$0 $0 80%

All Costs $0 20%



100%

$0

$0

PARTS A and B

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES --Medically necessary skilled care services and medical supplies --Durable medical equipment First $131 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

100% $0 80%

$0 $0 20%


7

ADVANTAGE65 SELECT B MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER




$0 $0 $0 $0 $0

$0 $0 $0 $0** All Costs



Same as any

other admission

Same as any

other admission




***Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits”. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

8

ADVANTAGE65 SELECT B MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (continued) * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER



$0 $0 $0

$0 $0 $0




$0 100%

3 pints $0

3 pints $0

$0 $0

$0 $0



$0

$0

Balance

Balance

9

ADVANTAGE65 SELECT B MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING


$0 Generally 80%

$0 Generally 20%

$0 $0




$0

$0

$0

All Costs

All Costs


$0 $0 80%

All Costs $0 20%

All Costs $0 20%




100%

$0

$0

$0

$0

10


MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER


$0 Generally 80%

$0 Generally 20%

$0 Generally 20%




$0

$0

$0

All Costs

All Costs







11


MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER


100% $0 80%

$0 $0 20%

$0 $0 20%



12

ADVANTAGE65 SELECT D MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER




$0 $0 $0 $0 $0

$0 $0 $0 $0** All Costs



Same as any

other admission

Same as any

other admission





13

ADVANTAGE65 SELECT D MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (continued) * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER



$0 Up to $124 a day $0

$0 Up to $124 a day $0

$0 $0 All costs

$0 $0 All costs


$0 100%

3 pints $0

3 pints $0

$0 $0

$0 $0



$0

$0

Balance

Balance

14

ADVANTAGE65 SELECT D MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING


$0 Generally 80%

$0 Generally 20%

$0 $0




$0

$0

$0

All Costs

All Costs


$0 $0 80%

All Costs $0 20%

All Costs $0 20%




100%

$0

$0

$0

$0

15

ADVANTAGE65 SELECT D MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR (continued) *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER


$0 Generally 80%

$0 Generally 20%

$0 Generally 20%




$0

$0

$0

All Costs

All Costs







16

ADVANTAGE65 SELECT D MEDICARE PARTS A & B *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER

HOME HEALTH CARE MEDICARE APPROVED SERVICES --Medically necessary skilled care services and medical supplies --Durable medical equipment -- First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts AT-HOME RECOVERY SERVICES— NOT COVERED BY MEDICARE Home care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan --Benefit for each visit --Number of visits covered (must be received within 8 weeks of last Medicare approved visit) --Calendar year maximum

100% $0 80% $0 $0 $0





17

ADVANTAGE65 SELECT D OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER


$0 $0





18

ADVANTAGE65 SELECT E MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE

PLAN PAYS

YOU PAY


NON-



NON-

PARTICIPATING

PROVIDER




$0 $0 $0 $0 $0

$0 $0 $0 $0** All Costs



Same as any

other admission

Same as any

other admission





19

ADVANTAGE65 SELECT E MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (continued) * A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY



$0 Up to $124 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0



$0

Balance

20

ADVANTAGE65 SELECT E MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY

MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies --First $131 of Medicare Approved Amounts* --Remainder of Medicare Approved Amounts

$0 Generally 80%

$0 Generally 20%



$0

$0

All Costs


$0 $0 80%

All Costs $0 20%



100%

$0

$0

21

ADVANTAGE65 SELECT E MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR (continued) *Once you have been billed $131 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY


$0 Generally 80%

$0 Generally 20%



$0

$0

All Costs






100% $0 80%

$0 $0 20%


22

ADVANTAGE65 SELECT E OTHER BENEFITS - NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN PAYS YOU PAY


$0 $0



*PREVENTIVE MEDICAL CARE BENEFIT - NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare -- First $120 each calendar year -- Additional charges

$0 $0

$120 $0

$0 All Costs

*Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

Documents

BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC · BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – Cover page: 1 of 2 Benefit Plans A, Select B,