2015 Senior Blue. Outline of Medicare Supplement Coverage. For Assistance

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1 2015 Senior Blue Outline of Medicare Supplement Coverage For Assistance Contact your local Blue Cross Blue Shield office or call us toll free: WyomingSeniorBlue.com 12/14

2 Standard Medicare Supplement Plans This chart shows the benefits included in each of the standard Medicare supplement plans. Every company Plans E, H, I, and J are no longer available for sale. Basic Benefits: Hospitalization Part A plus coverage for 365 additional days after Medicare benefits e Medical Expenses Part B (generally 20% of Medicare-approved expenses) or co-paym or co-payments. Blood First three pints of blood each year. Hospice Part A. Blue Cross Blue Shield of Wyoming offers the plans highlighted in gray. A B C D F F* * Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (100%) *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2,000 2,180 ( paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do n **The out-of-pocket annual limit may increase each year for inflation. Senior Blue is a registered mark of the Blue Cross and Blue Shield Associa

3 must make Plan A available. Some plans may not be available in your state. nd. ents for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B G K L M N Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%, except up to $20 copayment for office visit, and up to $50 copayment for ER 50% Skilled Nursing 75% Skilled Nursing Part A Deductible 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Part B Excess (100%) Out-of-pocket Out-of-pocket limit $4,940 $4,6 800; paid limit $2,330; 470; paid at 100% after at 100% after limit reached** limit reached** benefits as Plan F after one has paid a calendar year $2,180 $2,0 00 (2015 (2012 amount) deductible. amount). Out-of-pocket expenses for this deductible are expenses that would ordinarily be ot include the plan s separate foreign travel emergency deductible. tion, an Association of Independent Blue Cross and Blue Shield Plans.

4 5 High Deductible Ages Plan A Plan C Plan F Plan F Plan K Plan N

5 Senior Blue Medicare Supplement Plans This chart highlights the Senior Blue Medicare Supplement plans available to you. Benefit MEDICARE PAYS YOU PAY Senior Blue Plan A Medicare Part A Hospital Services Per Benefit Period Hospitalization Days 1-60 Days All but $1,260 All but $315 a day $1,260 (Part A Deductible) 91st Day and after: While using 60 lifetime reserve days All but $630 a day Once lifetime reserve days are used: Additional 365 days Beyond the 365 days All costs Care Days 1-20 All approved amounts Days st day and after All but $ a day Up to $ a day All costs Blood First three pints Additional amounts 100% Hospice Care All but limited for outpatient drugs & inpatient respite Medicare Part B Medical Services Per Calendar Year Medical Expenses First $147 of Medicare-approved amounts $147 (Part B Deductible) Remainder of Medicare-approved amounts Generally 80% Part B excess charges (above Medicare-approved amounts) All costs Blood First 3 pints Next $147 of Medicare-approved amounts $14 7 (Part B Deductible) Remainder of Medicare-approved amounts 80% Clinical Laboratory Service 100% Home Health Care Medicare-Approved Services Medically necessary skilled care, services, medical supplies 100% Durable medical equipment: First $147 of Medicare-approved amounts $147 (Part B Deductible) Remainder of Medicare-approved amounts 80% Other Services Not Covered by Medicare (Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA) First $250 of each calendar year All costs Remainder of charges All costs Senior Blue Medicare Supplement Plans are age-rated.

6 YOU PAY YOU PAY YOU PAY YOU PAY Senior Blue Plan C Senior Blue Plan F/F* Senior Blue Plan K** Senior Blue Plan N $630 (50% of Part A Deductible) All costs All costs All costs All costs Up to $78.75 a day All costs All costs All costs All costs 50% of the first three pints of blood 50% of Part A Medicare or copayments $147 (Part B Deductible) $147 (Part B Deductible) Generally 10% $20 Office Visit / $50 ER All costs All costs All costs 50% of the first three pints of blood $147 (Part B Deductible) $147 (Part B Deductible) Generally 10% $147 (Part B Deductible) $147 (Part B Deductible) 10% $250 $250 All Costs $250 20% and amounts over the 20% and amounts over the All Costs 20% and amounts over the $50,000 lifetime maximum $50,000 lifetime maximum $50,000 lifetime maximum * Plan F also has an option called a High Deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 $2,180 (for (for ) 4) ) deductible. ** Out-of-pocket maximum for Medicare-approved amounts limited to to $4,800 $4,940 for for

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