Medigap Outline of Coverage for Plans A, D, F, G and N

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1 Medigap Outline of Coverage for Plans A, D, F, G and N

2 Contents Understanding your premiums... 3 Choosing a plan is easy Coverage that meets your needs Learning more about your choices Applying is easy Call toll-free , Monday Saturday. TTY users should call 711.

3 Understanding your premiums Use the following charts to determine your Priority Health Medigap plan premium, which is effective as of April 1, 2015 or January 1, 2015 for Plan G For Priority Health Medigap plans, certain factors may affect your monthly premium. At the time of application, we base our premiums on the county you live in, as well as your age, gender, health status, use of tobacco products and eligibility for open enrollment or a guaranteed issue right. Once you re a Priority Health Medigap member, your premium amount is guaranteed for 12 months. You will receive one premium adjustment annually on the anniversary of your effective date. This will include an age adjustment which is an increase based on being one year older. It will also include any potential premium changes (increase or decrease). We may change the plan premiums each year but only if we change the premium for all members in the same plan (This premium change is subject to state approval). Your premium could also change if you move to a different area. After you become a member you may continue your coverage if you permanently move outside the State of Michigan. You must reside in Michigan for at least six months of every year to be considered a resident. If you reside in Michigan for less than six months, we will consider you to have permanently moved out of the state. If you remain living in the United States or one of its territories, you may continue your coverage provided all other eligibility requirements continue to be satisfied. After you move, your premium will change to the Area 2 premium. If you move outside of the United States or its territories your Priority Health Medigap plan will be terminated. The preferred premium always applies if you are in your open enrollment period or if you have a guaranteed issue right. It may also apply if you meet certain medical criteria when you are outside the open enrollment period or guaranteed issue right. A tier one or tier two premium may apply if you are no longer in your open enrollment period and/or do not have a guaranteed issue right. These premiums are based on your age, area you live in, health status and whether or not you use tobacco products. prioritymedicare.com 3

4 Area 1 Counties: Plan A Plan D Allegan Barry Berrien Branch Calhoun Cass Ionia Kalamazoo Kent Lake Mason Mecosta Montcalm Muskegon Newaygo Oceana Osceola Ottawa Saint Joseph Van Buren Age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female 65 $100 $94 $110 $103 $162 $151 $141 $132 $155 $145 $228 $ $104 $97 $115 $106 $168 $156 $147 $136 $162 $150 $237 $ $110 $101 $121 $111 $177 $162 $154 $142 $170 $156 $249 $ $115 $104 $127 $115 $186 $168 $162 $147 $178 $162 $261 $ $120 $108 $132 $119 $194 $175 $169 $152 $186 $168 $273 $ $126 $112 $138 $123 $203 $181 $177 $158 $195 $174 $285 $ $131 $116 $144 $128 $211 $187 $184 $163 $203 $180 $297 $ $136 $120 $150 $132 $220 $193 $192 $169 $211 $186 $309 $ $142 $124 $156 $136 $228 $200 $199 $174 $219 $192 $321 $ $147 $128 $161 $141 $237 $207 $206 $180 $227 $198 $333 $ $152 $132 $167 $146 $245 $213 $214 $186 $235 $205 $345 $ $157 $136 $173 $150 $253 $220 $221 $192 $243 $211 $356 $ $162 $141 $178 $155 $262 $227 $228 $198 $251 $218 $368 $ $166 $144 $183 $158 $268 $232 $234 $202 $258 $223 $378 $ $171 $147 $188 $162 $275 $237 $240 $207 $264 $228 $388 $ $175 $150 $193 $165 $282 $242 $246 $211 $271 $233 $397 $ $179 $154 $197 $169 $289 $248 $252 $216 $278 $238 $407 $ $184 $157 $202 $172 $296 $253 $258 $221 $284 $243 $417 $ $189 $161 $208 $177 $305 $260 $266 $227 $293 $249 $429 $ $195 $165 $214 $182 $314 $267 $274 $233 $301 $256 $442 $ $200 $170 $220 $186 $323 $273 $281 $238 $310 $262 $454 $385 Claims tax is not reflected in the premium amounts shown in this booklet and will be added to your monthly bill. 4 Call toll-free , Monday Saturday. TTY users should call 711.

5 Plan F Plan G Plan N Age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female 65 $162 $151 $178 $166 $261 $244 $140 $130 $154 $143 $226 $209 $118 $110 $130 $121 $190 $ $168 $156 $185 $171 $271 $251 $140 $130 $154 $143 $226 $209 $123 $114 $135 $125 $198 $ $177 $162 $194 $178 $285 $261 $147 $135 $162 $148 $237 $218 $129 $118 $142 $130 $208 $ $185 $168 $204 $185 $299 $271 $154 $140 $170 $154 $249 $226 $135 $123 $149 $135 $218 $ $194 $174 $213 $192 $312 $281 $162 $145 $178 $160 $261 $234 $141 $127 $155 $140 $228 $ $202 $180 $223 $199 $326 $291 $169 $150 $186 $166 $272 $243 $148 $132 $162 $145 $238 $ $211 $187 $232 $205 $340 $301 $176 $156 $193 $171 $284 $251 $154 $136 $169 $150 $248 $ $219 $193 $241 $212 $354 $311 $183 $161 $201 $177 $295 $259 $160 $141 $176 $155 $258 $ $228 $200 $251 $220 $367 $322 $190 $166 $209 $183 $306 $268 $166 $146 $183 $160 $268 $ $236 $206 $260 $227 $381 $333 $197 $172 $217 $189 $317 $277 $172 $150 $189 $165 $278 $ $244 $213 $269 $234 $394 $343 $204 $177 $224 $195 $329 $286 $178 $155 $196 $171 $287 $ $253 $220 $278 $241 $407 $354 $211 $183 $232 $201 $340 $295 $184 $160 $203 $176 $297 $ $261 $226 $287 $249 $421 $365 $218 $189 $239 $207 $351 $304 $190 $165 $209 $181 $307 $ $268 $231 $295 $255 $432 $373 $223 $193 $246 $212 $360 $311 $195 $169 $215 $186 $315 $ $275 $237 $302 $260 $443 $382 $229 $197 $252 $217 $370 $318 $200 $173 $220 $190 $323 $ $282 $242 $310 $266 $454 $390 $235 $202 $258 $222 $379 $325 $205 $176 $226 $194 $331 $ $289 $247 $318 $272 $466 $399 $241 $206 $265 $227 $388 $332 $211 $180 $232 $198 $340 $ $296 $252 $325 $278 $477 $407 $246 $210 $271 $231 $397 $339 $216 $184 $237 $202 $348 $ $304 $259 $335 $285 $491 $418 $254 $216 $279 $238 $409 $349 $222 $189 $244 $208 $358 $ $313 $266 $344 $293 $505 $429 $261 $222 $287 $244 $421 $358 $228 $194 $251 $213 $368 $ $322 $273 $354 $300 $519 $440 $268 $227 $295 $250 $433 $367 $235 $199 $258 $219 $379 $321 prioritymedicare.com 5

6 Area 2 Counties: Plan A Plan D Arenac Bay Clare Clinton Eaton Genesee Gladwin Gratiot Hillsdale Huron Ingham Isabella Jackson Lapeer Lenawee Livingston Macomb Midland Monroe Oakland Saginaw Sanilac Shiawassee St. Clair Tuscola Washtenaw Wayne Outside the state of Michigan Age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female 65 $96 $90 $106 $99 $155 $145 $136 $127 $149 $139 $219 $ $100 $93 $110 $102 $162 $150 $141 $131 $155 $144 $227 $ $105 $97 $116 $106 $170 $156 $148 $136 $163 $149 $239 $ $110 $100 $122 $110 $178 $162 $155 $141 $171 $155 $251 $ $116 $104 $127 $114 $186 $168 $163 $146 $179 $161 $262 $ $121 $108 $133 $118 $195 $174 $170 $152 $187 $167 $274 $ $126 $111 $138 $123 $203 $180 $177 $157 $195 $172 $286 $ $131 $115 $144 $127 $211 $186 $184 $162 $203 $178 $297 $ $136 $119 $149 $131 $219 $192 $191 $168 $210 $184 $308 $ $141 $123 $155 $135 $227 $198 $198 $173 $218 $190 $320 $ $146 $127 $160 $140 $235 $205 $205 $179 $226 $197 $331 $ $151 $131 $166 $144 $243 $211 $212 $184 $233 $203 $342 $ $156 $135 $171 $148 $251 $218 $219 $190 $241 $209 $353 $ $160 $138 $176 $152 $258 $223 $225 $194 $247 $214 $363 $ $164 $141 $180 $155 $264 $228 $231 $199 $254 $219 $372 $ $168 $144 $185 $159 $271 $233 $236 $203 $260 $223 $381 $ $172 $147 $189 $162 $278 $238 $242 $207 $267 $228 $391 $ $176 $151 $194 $166 $284 $243 $248 $212 $273 $233 $400 $ $182 $155 $200 $170 $293 $249 $255 $218 $281 $239 $412 $ $187 $159 $205 $175 $301 $256 $263 $223 $289 $246 $424 $ $192 $163 $211 $179 $310 $263 $270 $229 $297 $252 $436 $369 Claims tax is not reflected in the premium amounts shown in this booklet and will be added to your monthly bill. 6 Call toll-free , Monday Saturday. TTY users should call 711.

7 Plan F Plan G Plan N Age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female 65 $155 $145 $171 $159 $250 $234 $141 $130 $155 $143 $227 $210 $113 $106 $124 $116 $182 $ $161 $149 $177 $164 $260 $241 $141 $130 $155 $143 $227 $210 $118 $109 $129 $120 $190 $ $170 $155 $186 $171 $273 $251 $148 $136 $163 $149 $239 $219 $124 $113 $136 $125 $199 $ $178 $161 $196 $178 $287 $260 $155 $141 $171 $155 $250 $227 $130 $118 $143 $129 $209 $ $186 $167 $205 $184 $300 $270 $162 $146 $178 $161 $262 $235 $136 $122 $149 $134 $219 $ $194 $173 $214 $191 $313 $280 $169 $151 $186 $166 $273 $244 $142 $126 $156 $139 $229 $ $202 $179 $223 $197 $327 $289 $177 $156 $194 $172 $285 $252 $148 $131 $162 $144 $238 $ $211 $185 $232 $204 $340 $299 $184 $162 $202 $178 $296 $261 $154 $135 $169 $149 $248 $ $219 $192 $241 $211 $353 $309 $191 $167 $210 $184 $308 $270 $160 $140 $175 $154 $257 $ $227 $198 $249 $218 $366 $319 $198 $173 $217 $190 $319 $279 $165 $144 $182 $159 $267 $ $235 $204 $258 $225 $378 $330 $205 $178 $225 $196 $330 $288 $171 $149 $188 $164 $276 $ $243 $211 $267 $232 $391 $340 $212 $184 $233 $202 $341 $297 $177 $154 $195 $169 $285 $ $251 $217 $276 $239 $404 $350 $219 $189 $240 $208 $352 $306 $183 $158 $201 $174 $295 $ $257 $222 $283 $244 $415 $358 $224 $194 $247 $213 $362 $313 $188 $162 $206 $178 $303 $ $264 $227 $290 $250 $426 $366 $230 $198 $253 $218 $371 $320 $192 $166 $212 $182 $310 $ $270 $232 $298 $255 $436 $375 $236 $203 $260 $223 $381 $327 $197 $169 $217 $186 $318 $ $277 $237 $305 $261 $447 $383 $242 $207 $266 $228 $390 $334 $202 $173 $222 $190 $326 $ $284 $242 $312 $267 $458 $391 $248 $211 $272 $232 $399 $341 $207 $177 $228 $194 $334 $ $292 $249 $321 $274 $471 $401 $255 $217 $280 $239 $411 $350 $213 $181 $234 $200 $344 $ $301 $255 $331 $281 $485 $412 $262 $223 $288 $245 $423 $359 $219 $186 $241 $205 $354 $ $309 $262 $340 $288 $498 $422 $270 $228 $297 $251 $435 $368 $225 $191 $248 $210 $364 $308 prioritymedicare.com 7

8 Area 3 Counties: Alcona Alger Alpena Antrim Baraga Benzie Charlevoix Cheboygan Chippewa Crawford Delta Dickinson Emmet Gogebic Grand Traverse Houghton Iosco Iron Kalkaska Keweenaw Leelanau Luce Mackinac Manistee Marquette Menominee Missaukee Montmorency Ogemaw Ontonagon Oscoda Otsego Presque Isle Roscommon Schoolcraft Wexford Plan A Plan D Age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female 65 $94 $88 $104 $97 $152 $142 $133 $124 $146 $137 $214 $ $98 $91 $108 $100 $158 $147 $138 $128 $152 $141 $223 $ $103 $95 $113 $104 $166 $153 $145 $133 $160 $146 $234 $ $108 $98 $119 $108 $174 $158 $152 $138 $167 $152 $246 $ $113 $102 $125 $112 $183 $164 $159 $143 $175 $158 $257 $ $118 $105 $130 $116 $191 $170 $166 $148 $183 $163 $268 $ $123 $109 $136 $120 $199 $176 $173 $154 $191 $169 $280 $ $128 $113 $141 $124 $207 $182 $180 $159 $198 $174 $291 $ $133 $117 $146 $128 $215 $188 $187 $164 $206 $180 $302 $ $138 $121 $152 $133 $222 $194 $194 $170 $213 $187 $313 $ $143 $124 $157 $137 $230 $201 $201 $175 $221 $193 $324 $ $148 $128 $162 $141 $238 $207 $208 $180 $228 $199 $335 $ $152 $132 $168 $145 $246 $213 $215 $186 $236 $205 $346 $ $157 $135 $172 $149 $252 $218 $220 $190 $242 $209 $355 $ $161 $138 $177 $152 $259 $223 $226 $195 $249 $214 $364 $ $165 $141 $181 $155 $266 $228 $232 $199 $255 $219 $374 $ $169 $144 $186 $159 $272 $233 $237 $203 $261 $223 $383 $ $173 $147 $190 $162 $279 $238 $243 $207 $267 $228 $392 $ $178 $151 $196 $167 $287 $244 $250 $213 $275 $234 $404 $ $183 $155 $201 $171 $295 $251 $257 $219 $283 $241 $415 $ $188 $159 $207 $175 $303 $257 $265 $224 $291 $247 $427 $362 Claims tax is not reflected in the premium amounts shown in this booklet and will be added to your monthly bill. 8 Call toll-free , Monday Saturday. TTY users should call 711.

9 Plan F Plan G Plan N Age Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Preferred Tier 1 Tier 2 Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female 65 $152 $142 $167 $156 $245 $229 $137 $127 $150 $139 $220 $204 $111 $104 $122 $114 $179 $ $158 $146 $174 $161 $255 $236 $137 $127 $150 $139 $220 $204 $115 $107 $127 $117 $186 $ $166 $152 $183 $167 $268 $245 $144 $132 $158 $145 $231 $212 $121 $111 $133 $122 $195 $ $174 $158 $192 $174 $281 $255 $151 $137 $166 $150 $243 $220 $127 $115 $140 $127 $205 $ $182 $164 $200 $180 $294 $264 $157 $142 $173 $156 $254 $229 $133 $120 $146 $131 $214 $ $190 $170 $209 $187 $307 $274 $164 $147 $181 $161 $265 $237 $139 $124 $153 $136 $224 $ $198 $176 $218 $193 $320 $283 $171 $152 $189 $167 $277 $245 $145 $128 $159 $141 $233 $ $206 $181 $227 $200 $333 $293 $178 $157 $196 $173 $288 $253 $151 $132 $166 $146 $243 $ $214 $188 $236 $206 $345 $303 $185 $162 $204 $178 $299 $262 $156 $137 $172 $151 $252 $ $222 $194 $244 $213 $358 $313 $192 $168 $211 $184 $309 $270 $162 $141 $178 $156 $261 $ $230 $200 $253 $220 $371 $323 $199 $173 $218 $190 $320 $279 $168 $146 $184 $161 $270 $ $238 $206 $261 $227 $383 $333 $205 $178 $226 $196 $331 $288 $173 $151 $191 $166 $279 $ $245 $213 $270 $234 $396 $343 $212 $184 $233 $202 $342 $297 $179 $155 $197 $171 $289 $ $252 $218 $277 $239 $406 $351 $218 $188 $240 $207 $351 $303 $184 $159 $202 $175 $296 $ $258 $223 $284 $245 $417 $359 $223 $192 $246 $212 $360 $310 $188 $162 $207 $179 $304 $ $265 $227 $291 $250 $427 $367 $229 $197 $252 $216 $369 $317 $193 $166 $213 $182 $312 $ $271 $232 $299 $256 $438 $375 $235 $201 $258 $221 $378 $324 $198 $169 $218 $186 $319 $ $278 $237 $306 $261 $448 $383 $240 $205 $264 $226 $388 $331 $203 $173 $223 $190 $327 $ $286 $244 $315 $268 $462 $393 $247 $211 $272 $232 $399 $340 $209 $178 $230 $196 $337 $ $294 $250 $324 $275 $475 $403 $255 $216 $280 $238 $411 $349 $215 $182 $236 $201 $346 $ $303 $257 $333 $282 $488 $414 $262 $222 $288 $244 $422 $358 $221 $187 $243 $206 $356 $302 prioritymedicare.com 9

10 A healthier approach to health care Priority Health is dedicated to improving the health and lives of our members. That means we do what it takes to make sure you get the quality care you need, when you need it. We re committed to making it easier for you to understand your coverage options and how to get the most from your health plan. You can depend on Priority Health for excellent coverage no matter which plan you choose. Service you can count on Local, friendly customer service available 7 days a week to answer questions Based in Michigan, with more than 26+ years of experience improving member health 97% of our Medicare members would recommend us to their friends and family* Call us toll-free at or contact your local agent. * July 2013 Priority Health Medicare research report conducted by Kiekover Marketing.

11 Choosing a plan is easy We have what you re looking for in a Medigap plan. With a Priority Health Medigap plan, you ll be protected from large medical bills with reliable, easy-to-understand coverage. The coverage you need If you have Original Medicare, you re covered for many hospital and medical expenses. But you may be surprised how quickly your deductibles, copays and coinsurance can add up. Can you afford the coverage gaps in Original Medicare? For example, in 2015, if you go to the hospital, you will need to pay a $1,260 deductible right away, before your coverage begins. If you need to be in the hospital for a long time, you ll pay $315 per day for days 61 90, then $630 each day after 90 days. To avoid paying for these costly coverage gaps, consider a Priority Health Medigap plan to help with these expenses. Learn more Visit our website at prioritymedicare.com for additional plan information and 24/7 answers to your questions. Priority Health offers Medicare Supplement Plan A, Plan D, Plan F, Plan G and Plan N. The federal government standardizes all of the plans. See page 13 for more complete information about each plan. prioritymedicare.com 11

12 Coverage that meets your needs Live with confidence because you know you re covered. The freedom to go to any doctor or hospital who accepts Medicare, anywhere in the country Virtually no claims paperwork for you Online health risk appraisal and healthy living resources No hidden fees no application or association fee on top of your monthly premium No referral needed to see a specialist Worldwide emergency coverage** Reduced prices for fitness clubs, clothing, equipment and more **Plan D, F, G and N A guarantee that your rate can only change once every 12 months Enjoy easy renewal Once you ve enrolled in a Priority Health Medigap plan, the rest is easy. Your claims are processed automatically, and we ll pay your providers directly. Your coverage will automatically be renewed each year as long as you pay your premiums. 12 Call toll-free , Monday Saturday. TTY users should call 711.

13 Choose the benefits that are most important to you Medicare Supplement insurance can be sold in only 11 standard plans, one of which is a high deductible plan. The following chart shows the benefits included in each plan. Every insurer must offer Plan A. Some plans may not be available in your state. Priority Health offers Plans A, D, F, G and N. Basic benefits included in all Medigap plans: Hospitalization: Part A copayments plus coverage for 365 additional days after Medicare benefits end Medical expenses: Part B coinsurance (20% of Medicare-approved expenses) or copays. Plans K, L and N require you to pay a portion of the Part B coinsurance or copayments Medicare preventive care: Part B coinsurance (20% of Medicareapproved expenses) when applicable Blood: First three pints of blood each year (Original Medicare covers additional pints) Hospice: Part A coinsurance for inpatient respite care and copays for outpatient prescription drugs Additional benefits available in select Medigap plans: Hospitalization: Part A deductible per Benefit Period ($1,260 in 2015) Skilled nursing facility care: Part A daily copayments for days 21 through 100 of each Benefit Period Medical expenses: Part B deductible per calendar year ($147 in 2015) Part B excess charges: All costs above Medicare approved amounts Foreign travel emergency care: 80% of Medicare eligible expenses for emergency care services received outside the U.S. after you meet a foreign travel deductible prioritymedicare.com 13

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15 Benefits included in all Medigap plans Benefits Inpatient hospital services Medicare Part A daily copayments plus an additional 365 days of coverage after Medicare benefits end Hospice care Medicare Part A coinsurance and copayments Medicare preventive care Medicare Part B coinsurance when applicable Medical expenses Medicare Part B coinsurance Plans A B C D F F* G K** L** M N 50% 75% 50% 75% 100% except up to a $20 office visit copayment and up to a $50 emergency visit copayment Blood First 3 pints under Medicare Parts A and B 50% 75% Skilled nursing facility care Medicare Part A daily copayments 50% 75% Medicare Part A deductible 50% 75% 50% Medicare Part B deductible Medicare Part B excess charges Foreign travel Emergency services 80% 80% 80% 80% 80% 80% 80% Out-of-pocket annual limit*** $4,000 $2,000 All benefits listed are covered at 100% unless the chart indicates otherwise. The Medigap plan covers copayments/coinsurances only after the deductible is met unless the plan covers it. *Plan F has an option called a high deductible plan F. This high deductible plan pays the same benefits as plan F after you have paid a calendar year deductible of $2000. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2000. Out-of pocket expenses for this deductible are expenses that would ordinarily be paid by the plan. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. **Plans K and L include the same basic benefits as the other Medigap plans, but the cost-sharing you pay for the basic benefits is at different levels. Once you reach the out-of-pocket 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. prioritymedicare.com 15

16 Medigap Plans A, D, F, G & N All dollar amounts shown are the 2015 Original Medicare numbers. The benefits and costs shown below are for plans effective on or after January 1, Plan A Plan D Services Original Medicare Pays Plan Pays You Pay Plan Pays You Pay Medicare (Part A) hospital services per benefit period Hospitalization* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,260 $1,260 (Part A deductible) $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day $315 a day 91st day and after (while using 60 lifetime reserve days) All but $630 a day $630 a day $630 a day Once lifetime reserve days are used; additional 365 days 100% of Medicare eligible expenses ** 100% of Medicare eligible expenses ** Beyond the additional 365 days All costs 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 100% 21st thru 100th day All but $ a day Up to $ a day Up to $ a day 101st day and after All costs All costs Blood First 3 pints 3 pints 3 pints Additional amounts 100% Hospice care Available as long as your doctor certifies you are terminally ill and you elect to receive these services Hospice care 100% Outpatient prescription drugs All but $5 per prescription $5 per prescription $5 per prescription Inpatient respite care 95% 5% of Medicare eligible expenses 5% of Medicare eligible expenses Medicare (Part B) medical services per calendar year. 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 $147 of Medicare approved amounts $147 $147 (Part B deductible***) Remainder of Medicare approved amounts (after deductible is met) Part B excess charges (above Medicare approved amounts) 80% 20% 20% All costs All costs * 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. ** NOTICE: When your Medicare Part A hospital benefits are exhausted, Priority Health stands in the place of Medicare and pays whatever amount Medicare would have paid for up to an additional 365 days. During this time the hospital can t bill you for the balance based on any difference between its billed charges and the amount Medicare would have paid. 16 Call toll-free , Monday Saturday. TTY users should call 711.

17 Plan F Plan G Plan N Plan Pays You Pay Plan Pays You Pay Plan Pays You Pay $1,260 (Part A deductible) $1,260 (Part A deductible) $1,260 (Part A deductible) $315 a day $315 a day $315 a day $630 a day $630 a day $630 a day 100% of Medicare eligible expenses ** 100% of Medicare eligible expenses ** 100% of Medicare eligible expenses ** All costs All costs All costs Up to $ a day Up to $ a day Up to $ a day All costs All costs All costs 3 pints 3 pints 3 pints $5 per prescription $5 per prescription $5 per prescription 5% of Medicare eligible expenses 5% of Medicare eligible expenses 5% of Medicare eligible expenses $147 $147 $147 20% 20% 20% except up to a $20 office visit and up to a $50 emergency visit copay. Up to $20 per office visit. Up to $50 per emergency room visit. All costs All costs All costs *** The Part B deductible needs to be met only once each calendar year (January 1 December 31). Once you have been billed $147 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. Emergency visit copay waived and visit covered as a Part A expense if you are admitted to any hospital. prioritymedicare.com 17

18 Medigap Plans A, D, F, G & N (continued) All dollar amounts shown are the 2015 Original Medicare numbers. The benefits and costs shown below are for plans effective on or after January 1, Plan A Plan D Services Original Medicare Pays Plan Pays You Pay Plan Pays You Pay Medicare preventive care First $147 of Medicare approved amounts (Part B deductible***) when applicable $147 $147 Medicare approved amounts (after deductible is met) when applicable Blood 80% 20% 20% First 3 pints 3 pints 3 pints Next $147 of Medicare approved amounts (Part B deductible***) Remainder of Medicare approved amounts (after deductible is met) Clinical laboratory services $147 $147 80% 20% 20% Tests for diagnostic services 100% Parts A & B Home health care Medicare approved services Medically necessary skilled care services and medical supplies 100% Durable medical equipment first $147 of Medicare-approved amounts $147 $147 (Part B deductible***) Remainder of Medicare-approved amounts for durable medical equipment (after 80% 20% 20% deductible is met) Other benefits (services not covered by Medicare) Foreign travel Emergency care services beginning during the first 60 days of each trip outside the U.S. $250 foreign travel deductible that must be met once each calendar year Remainder of charges after the foreign travel deductible is met up to a lifetime maximum of $50,000 All costs $250 All costs 80% 20% 18 Call toll-free , Monday Saturday. TTY users should call 711.

19 Plan F Plan G Plan N Plan Pays You Pay Plan Pays You Pay Plan Pays You Pay $147 $147 $147 20% 20% 20% 3 pints 3 pints 3 pints $147 $147 $147 20% 20% 20% $147 $147 $147 20% 20% 20% $250 $250 $250 80% 20% 80% 20% 80% 20% *** The Part B deductible needs to be met only once each calendar year (January 1 December 31). Once you have been billed $147 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. Member pays all amounts over $50,000. prioritymedicare.com 19

20 Learning more about your choices You can learn more about Priority Health Medigap plans on the phone, online or in person. Ask a question, research your options or attend a presentation it s easy to connect with Priority Health Medigap. Call our Medigap experts Get one-on-one help when you call seven days a week. TTY users should call 711. Go online Visit prioritymedicare.com to view your options. Attend a free Medicare Explained meeting Call us at the number listed at the bottom of this page or go online to find dates and locations near you. 20 Call toll-free , Monday Saturday. TTY users should call 711.

21 Important information Eligibility At the time of enrollment you must be: 65 or older Enrolled in Medicare Parts A and B A permanent resident of the State of Michigan (physically residing there six months of every year). Replacing your current coverage If you are replacing your current health insurance policy with a Priority Health Medigap plan, do not cancel your current insurance right away. Wait until you have received your new Medigap certificate and are sure you want to keep it. It s important for you to understand your plan You can use this outline of coverage to compare benefits and premiums among different policies, certificates and contracts. Please keep in mind that this is only an outline of the most important features of the plans. The certificate is your insurance contract. Be sure to read the certificate itself so you understand all of your rights and duties, and you understand the rights and duties of your health plan. If you change your mind We want you to be satisfied with your coverage, so please take time to review it carefully. If you are not satisfied with your certificate, you may return it to: Priority Health Enrollment Department, MS East Beltline NE Grand Rapids, MI If you send the certificate back to us within 30 days after it comes to you, we will act as though the certificate was never issued, and we will return all of your payments. We can collect from you all costs for covered services that you received and we paid. Notice: Please be aware that this outline of coverage does not include all the details of your Medigap (Medicare Supplement) coverage, and this plan may not fully cover all of your medical costs. Neither Priority Health Medigap plans nor agents authorized to sell Priority Health Medigap plans are connected with or endorsed by the United States government or the federal Medicare program. This outline of coverage does not give all the details of your Medicare coverage. For information about your Part A and Part B coverage, contact your local Social Security Office or consult the Medicare and You handbook for more details. prioritymedicare.com 21

22

23 Applying is easy To apply for any of our Priority Health Medigap plans: You must be enrolled in Medicare Part A and Part B Once you ve chosen a plan, there are two ways to apply: Note: By mail Fill out the application included in this packet. After you complete it, mail it back to us in the enclosed self-addressed envelope. If you don t have the envelope, you can mail it to: Priority Health Enrollment Department, MS E. Beltline, NE Grand Rapids, MI Be detailed and complete when applying for coverage. When you fill out your application, be sure to answer all questions truthfully and completely. Priority Health may cancel your plan and refuse to pay any claims if you leave out information or falsify important information. Review your application carefully before you sign it to be sure that all information has been recorded properly. Online Go to prioritymedicare.com and follow the directions for completing and submitting the application. prioritymedicare.com 23

24 A healthier approach to health care 2014 Priority Health prioritymedicare.com 2579 MG006(B) 8505H 11/14

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