MedicareBlue SupplementSM

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1 MedicareBlue Supplement SM MedicareBlue SupplementSM Choose from five Medicare Supplement Plans M /12 M / enrollment kit

2 I need a Medicare supplement plan I can depend on. Get reliable, secure coverage from a company you can trust. SM MedicareBlue Supplement PRODUCT GUIDE

3 Finding the MedicareBlue Supplement SM plan that s right for you As a unique individual with specific health care coverage needs, it s important to find the right combination of benefits, premiums and out-of-pocket costs to fit your needs. Let Wellmark help you find the plan that will work best for you. Are you looking for... Comprehensive coverage with the greatest benefit package? Take a look at PLAN F If you re looking for a plan that s hassle-free, Plan F may be for you. Just pay your monthly premiums and Plan F takes care of the rest, including any differences with Part B excess charges. Comprehensive coverage with a lower price tag? Take a look at HIGH DEDUCTIBLE PLAN F This plan may be the one for you if you re looking for the same comprehensive coverage as regular Plan F at a fraction of the premium price. Once you meet the annual deductible, this plan steps in and takes care of the rest, just like regular Plan F. Also, if your needs change, you have the flexibility to move to the regular Plan F without answering health questions after one year during the Annual Election Period. Lower cost monthly premiums in exchange for small copays? Take a look at PLAN N If you re used to a more traditional employer-sponsored health plan, then Plan N may be just right for you. With this plan, you pay less in monthly premiums in exchange for small copays of up to $20 for office visits and up to $50 for emergency room visits 1. Broad benefits with a lower premium? Take a look at PLAN D You may find that Plan D is the perfect fit for you if you visit a doctor or hospital that accepts Medicare and you don t mind paying the Part B deductible. Basic benefits and guaranteed acceptance? Take a look at PLAN A You don t need to worry about being denied coverage from Wellmark with this plan. Wellmark guarantees coverage with Plan A, so regardless of any health issues you may have, you ll be covered by this plan.

4 Discover why nearly 3 out of 5 Iowans with Medicare supplement coverage have already chosen Wellmark 2. Standardized plans don t mean standardized perks Get more from your Medicare supplement coverage when you choose Wellmark. Who doesn t love to get the most for their money? When you choose Wellmark, in addition to receiving the standard Medicare supplement benefits, you can count on: STABILITY AND SECURITY, INCLUDED WITH EVERY PLAN. As a Wellmark member, you can have confidence in your coverage knowing we re working hard to keep premiums as stable as possible. ACCESS TO EXCLUSIVE DISCOUNTS. Members can use the Blue365 discount program to access special discounts on vision and hearing services, fitness resources, travel and more. HOMEGROWN CUSTOMER SERVICE. When you call, you know you can trust the voice on the other end of the phone. We live and work right here in Iowa, and are proud to have been serving Iowans for 75 years. HEALTHY ADVANTAGES. If you live a healthy lifestyle, you may be eligible for preferred monthly premiums 3. FREEDOM OF CHOICE. Visit any Medicareparticipating doctor or hospital you want with no referrals and relax knowing you re covered if you re traveling across the state or across the country. Contact us with questions or for more information. We re here to help find a plan that s right for you. Call a Wellmark representative at (TTY hearing impaired call 711) 8 a.m. to 5 p.m., Monday - Friday, Central time Visit us online at: Wellmark.com/Medicare Contact your authorized Wellmark representative

5 Wellmark Blue Cross and Blue Shield of Iowa is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield, and the Cross and Shield Symbols and Blue365 are registered marks, and MedicareBlue Supplement SM is a service mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark is a registered mark of Wellmark, Inc Wellmark, Inc. This is a solicitation of insurance. MedicareBlue Supplement plans presented in this brochure are specific to Wellmark Blue Cross and Blue Shield of Iowa and can only be purchased by Iowa residents. Enrollment and coverage in a MedicareBlue Supplement insurance plan is with Wellmark Blue Cross and Blue Shield of Iowa, an independent licensee of the Blue Cross and Blue Shield Association. MedicareBlue Supplement insurance plans and the Blue365 member discount program are not connected with or endorsed by the U.S. government or the federal Medicare program. These policies have exclusions and limitations. For costs and complete details of coverage, contact Wellmark Blue Cross and Blue Shield of Iowa or your authorized independent agent. 1 The copay of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. 2 Source: NAIC data trend, Eligiblity for preferred premiums is dependent upon your answers to health questions on the application. M /14

6 SM MedicareBlue Supplement Plans A, D, F, High Deductible F, and N 2015 Outlines of Coverage Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after January 1, 2015 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in your state. Basic Benefits Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L and N require members to pay a portion of Part B coinsurance or copayments. Blood: First three pints of blood each year. Hospice: Part A coinsurance. Standard Medicare Supplement Plans Basic, including 100% Part B coinsurance A B C D F F HD G Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Basic, including 100% Part B coinsurance HD Skilled Nursing Facility Coinsurance Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part B Deductible Foreign Travel Emergency Foreign Travel Emergency Plans shaded in gray are offered by Wellmark Blue Cross and Blue Shield of Iowa. Part B Deductible Part B Excess (100%) Foreign Travel Emergency HD 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 $2,180 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. 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. Part B Excess (100%) Foreign Travel Emergency

7 MedicareBlue Supplement Preferred Non-Tobacco Premiums Standard Medicare Supplement Plans continued... Basic Benefits Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency K L M N Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $4,940; plan pays at 100% after limit is reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,470; plan pays at 100% after limit is reached Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Plans shaded in gray are offered by Wellmark Blue Cross and Blue Shield of Iowa. See Outlines of Coverage for details and explanations of the plans offered by Wellmark Blue Cross and Blue Shield. Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Premiums effective January 1, 2015, for Iowa residents. Applicants should refer to the 2015 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums. High Deductible Age Plan D Plan F Plan N Plan F Male Female Male Female Male Female Male Female Age 64 & Under $ $ $ $ $ $ $ $ Age 65 $ $ $ $ $63.80 $56.30 $90.50 $80.10 Age 66 $ $ $ $ $65.70 $58.20 $93.40 $82.60 Age 67 $ $ $ $ $67.90 $59.90 $96.30 $85.20 Age 68 $ $ $ $ $69.90 $61.90 $99.20 $87.80 Age 69 $ $ $ $ $72.20 $63.80 $ $90.60 Age 70 $ $ $ $ $74.10 $65.50 $ $93.00 Age 71 $ $ $ $ $80.50 $71.10 $ $ Age 72 $ $ $ $ $82.80 $73.30 $ $ Age 73 $ $ $ $ $85.30 $75.40 $ $ Age 74 $ $ $ $ $87.90 $77.70 $ $ Age 75 $ $ $ $ $90.50 $80.00 $ $ Age 76 $ $ $ $ $94.90 $83.90 $ $ Age 77 $ $ $ $ $99.60 $88.10 $ $ Age 78 $ $ $ $ $ $92.70 $ $ Age 79 $ $ $ $ $ $97.30 $ $ Age 80 $ $ $ $ $ $ $ $ Age 81 & Over $ $ $ $ $ $ $ $ Premiums are based upon the most currently available Medicare deductible and cost-sharing amounts. These premiums are subject to changes in the Medicare amounts for covered cost-sharing and deductibles. If you are applying for non-guaranteed issue Plans D, F, High Deductible Plan F, or N during the following periods you do not have to answer health questions on the application: (1) within six months following the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B or (2) during a Guaranteed Issue Rights period. 2 3

8 MedicareBlue Supplement Preferred Tobacco Premiums MedicareBlue Supplement Standard Non-Tobacco Premiums Premiums effective January 1, 2015, for Iowa residents. Applicants should refer to the 2015 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums. High Deductible Age Plan D Plan F Plan N Plan F Male Female Male Female Male Female Male Female Age 64 & Under $ $ $ $ $ $ $ $ Age 65 $ $ $ $ $70.20 $62.00 $99.60 $88.10 Age 66 $ $ $ $ $72.30 $64.00 $ $90.80 Age 67 $ $ $ $ $74.70 $65.90 $ $93.70 Age 68 $ $ $ $ $76.90 $68.10 $ $96.60 Age 69 $ $ $ $ $79.40 $70.20 $ $99.70 Age 70 $ $ $ $ $81.50 $72.10 $ $ Age 71 $ $ $ $ $88.50 $78.20 $ $ Age 72 $ $ $ $ $91.10 $80.60 $ $ Age 73 $ $ $ $ $93.80 $83.00 $ $ Age 74 $ $ $ $ $96.70 $85.50 $ $ Age 75 $ $ $ $ $99.60 $88.00 $ $ Age 76 $ $ $ $ $ $92.30 $ $ Age 77 $ $ $ $ $ $96.90 $ $ Age 78 $ $ $ $ $ $ $ $ Age 79 $ $ $ $ $ $ $ $ Age 80 $ $ $ $ $ $ $ $ Age 81 & Over $ $ $ $ $ $ $ $ Premiums are based upon the most currently available Medicare deductible and cost-sharing amounts. These premiums are subject to changes in the Medicare amounts for covered cost-sharing and deductibles. If you are applying for non-guaranteed issue Plans D, F, High Deductible Plan F, or N during the following periods you do not have to answer health questions on the application: (1) within six months following the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B or (2) during a Guaranteed Issue Rights period. Premiums effective January 1, 2015, for Iowa residents. Applicants should refer to the 2015 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums. High Deductible Age Plan A Plan D Plan F Plan N Plan F Male Female Male Female Male Female Male Female Male Female Age 64 & Under $ $ $ $ $ $ $ $ $ $ Age 65 $ $95.90 $ $ $ $ $74.70 $66.00 $ $92.10 Age 66 $ $99.10 $ $ $ $ $77.00 $68.20 $ $94.90 Age 67 $ $ $ $ $ $ $79.50 $70.20 $ $97.90 Age 68 $ $ $ $ $ $ $81.90 $72.50 $ $ Age 69 $ $ $ $ $ $ $84.60 $74.70 $ $ Age 70 $ $ $ $ $ $ $86.80 $76.80 $ $ Age 71 $ $ $ $ $ $ $94.30 $83.30 $ $ Age 72 $ $ $ $ $ $ $97.00 $85.90 $ $ Age 73 $ $ $ $ $ $ $99.90 $88.40 $ $ Age 74 $ $ $ $ $ $ $ $91.10 $ $ Age 75 $ $ $ $ $ $ $ $93.70 $ $ Age 76 $ $ $ $ $ $ $ $98.30 $ $ Age 77 $ $ $ $ $ $ $ $ $ $ Age 78 $ $ $ $ $ $ $ $ $ $ Age 79 $ $ $ $ $ $ $ $ $ $ Age 80 $ $ $ $ $ $ $ $ $ $ Age 81 & Over $ $ $ $ $ $ $ $ $ $ You do not have to answer health questions if you apply for Plan A. Premiums are based upon the most currently available Medicare deductible and cost-sharing amounts. These premiums are subject to changes in the Medicare amounts for covered cost-sharing and deductibles. If you are applying for non-guaranteed issue Plans D, F, High Deductible Plan F, or N during the following periods you do not have to answer health questions on the application: (1) within six months following the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B or (2) during a Guaranteed Issue Rights period. 4 5

9 MedicareBlue Supplement Standard Tobacco Premiums Premiums effective January 1, 2015, for Iowa residents. Applicants should refer to the 2015 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums. High Deductible Age Plan A Plan D Plan F Plan N Plan F Male Female Male Female Male Female Male Female Male Female Age 64 & Under $ $ $ $ $ $ $ $ $ $ Age 65 $ $ $ $ $ $ $82.20 $72.60 $ $ Age 66 $ $ $ $ $ $ $84.70 $75.00 $ $ Age 67 $ $ $ $ $ $ $87.50 $77.20 $ $ Age 68 $ $ $ $ $ $ $90.10 $79.70 $ $ Age 69 $ $ $ $ $ $ $93.10 $82.20 $ $ Age 70 $ $ $ $ $ $ $95.40 $84.50 $ $ Age 71 $ $ $ $ $ $ $ $91.60 $ $ Age 72 $ $ $ $ $ $ $ $94.40 $ $ Age 73 $ $ $ $ $ $ $ $97.20 $ $ Age 74 $ $ $ $ $ $ $ $ $ $ Age 75 $ $ $ $ $ $ $ $ $ $ Age 76 $ $ $ $ $ $ $ $ $ $ Age 77 $ $ $ $ $ $ $ $ $ $ Age 78 $ $ $ $ $ $ $ $ $ $ Age 79 $ $ $ $ $ $ $ $ $ $ Age 80 $ $ $ $ $ $ $ $ $ $ Age 81 & Over $ $ $ $ $ $ $ $ $ $ You do not have to answer health questions if you apply for Plan A. Premiums are based upon the most currently available Medicare deductible and cost-sharing amounts. These premiums are subject to changes in the Medicare amounts for covered cost-sharing and deductibles. If you are applying for non-guaranteed issue Plans D, F, High Deductible Plan F, or N during the following periods you do not have to answer health questions on the application: (1) within six months following the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B or (2) during a Guaranteed Issue Rights period. Premium Information Wellmark Blue Cross and Blue Shield can only raise your premium if we raise the premium for all policies like yours in this state. When we change the premium upon our implementation of a new table of premiums or a change in Medicare s benefit structure, your new premium will be based upon your age at the effective date of the premium change. If we do change your premium, we will notify you at least 30 days in advance. However, if you are applying for coverage within 60 days of a premium change with an effective date prior to the premium change, Wellmark will provide notice of the new premium within a reasonable period of the time after the enrollment of your application. Disclosures Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, Policies sold for effective dates prior to June 1, 2010, have different benefits and premiums. Read Your Policy Very Carefully This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. Right to Return Policy If you find that you are not satisfied with your policy, you may return it to: Wellmark Blue Cross and Blue Shield of Iowa P.O. Box Des Moines, IA If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. Policy Replacement If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. Notice This policy may not fully cover all of your medical costs. Neither Wellmark Blue Cross and Blue Shield of Iowa nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare and You for more details. Complete Answers Are Very Important When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. Wellmark Blue Cross and Blue Shield may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. 6 7

10 MedicareBlue Supplement Plan A Medicare (Part A) Hospital Services Per Benefit Period Services Medicare Pays Plan A Pays You Pay Hospitalization 1 Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $0 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day $0 91st day and after While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare eligible expenses Beyond the additional 365 days $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st thru 100th day All but $ a day $0 Up to $ a day 101st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare s requirements, including doctor s certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 2 $0 Medicare (Part B) Medical Services Per Calendar Year Services Medicare Pays Plan A 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 $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Part B Excess Charges (Above Medicare approved amounts) Blood Generally 80% Generally 20% $0 $0 $0 All costs First 3 pints $0 All costs $0 Next $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Clinical Laboratory Services TESTS FOR DIAGNOSTIC SERVICES 80% 20% $0 100% $0 $0 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. 1 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. 2 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 Basic 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 9

11 MedicareBlue Supplement Plan A (continued) MedicareBlue Supplement Plan D Medicare Parts A & B Services Medicare Pays Plan A Pays You Pay Home Health Care MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment: First $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts 80% 20% $0 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. Medicare (Part A) Hospital Services Per Benefit Period Services Medicare Pays Plan D Pays You Pay Hospitalization 1 Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day $0 91st day and after While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare eligible expenses Beyond the additional 365 days $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st thru 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare s requirements, including doctor s certification of terminal illness. All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 $0 2 $0 1 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. 2 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 Basic 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

12 MedicareBlue Supplement Plan D (continued) Medicare (Part B) Medical Services Per Calendar Year Services Medicare Pays Plan D 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 $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Part B Excess Charges (Above Medicare approved amounts) Blood Generally 80% Generally 20% $0 $0 $0 All costs First 3 pints $0 All costs $0 Next $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Clinical Laboratory Services TESTS FOR DIAGNOSTIC SERVICES 80% 20% $0 100% $0 $0 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. Medicare Parts A & B Services Medicare Pays Plan D Pays You Pay Home Health Care MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipment: First $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Other Benefits Not Covered by Medicare 80% 20% $0 Services Medicare Pays Plan D Pays You Pay 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. 20% and amounts over the $50,000 lifetime maximum Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare

13 MedicareBlue Supplement Plan F Medicare (Part A) Hospital Services Per Benefit Period Services Medicare Pays Plan F Pays You Pay Hospitalization 1 Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day $0 91st day and after While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare eligible expenses Beyond the additional 365 days $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st thru 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare s requirements, including doctor s certification of terminal illness. All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 $0 2 $0 Medicare (Part B) Medical Services Per Calendar Year Services Medicare Pays Plan F 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 $147 of Medicare approved $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Part B Excess Charges (Above Medicare approved amounts) Blood $0 Generally 80% Generally 20% $0 $0 100% $0 First 3 pints $0 All costs $0 Next $147 of Medicare approved $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Clinical Laboratory Services TESTS FOR DIAGNOSTIC SERVICES $0 80% 20% $0 100% $0 $0 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. 1 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. 2 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 Basic 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

14 MedicareBlue Supplement Plan F (continued) MedicareBlue Supplement High Deductible Plan F Medicare Parts A & B Services Medicare Pays Plan F Pays You Pay Home Health Care MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment: First $147 of Medicare approved $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Other Benefits Not Covered by Medicare $0 80% 20% $0 Services Medicare Pays Plan F Pays You Pay 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 20% and amounts over the $50,000 lifetime maximum Medicare (Part A) Hospital Services Per Benefit Period Services Hospitalization 1 Semiprivate room and board, general nursing and miscellaneous services and supplies Medicare Pays After you pay $2,180 deductible Plan F HD Pays First 60 days All but $1,260 $1,260 (Part A deductible) $0 61st thru 90th day All but $315 a day $315 a day $0 91st day and after While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare eligible expenses You Pay Beyond the additional 365 days $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st thru 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare s requirements, including doctor s certification of terminal illness. All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance $0 2 $0 HD This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $2,180 deductible. Benefits from the High Deductible Plan F will not begin until out-of-pocket expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. 1 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. 2 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 Basic Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference 16 between its billed charges and the amount Medicare would have paid. 17

15 MedicareBlue Supplement High Deductible Plan F (continued) Medicare (Part B) Medical Services Per Calendar Year Services 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 Medicare Pays After you pay $2,180 deductible Plan F HD Pays First $147 of Medicare approved $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Part B Excess Charges (Above Medicare approved amounts) Blood You Pay $0 Generally 80% Generally 20% $0 $0 100% $0 First 3 pints $0 All costs $0 Next $147 of Medicare approved $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Clinical Laboratory Services TESTS FOR DIAGNOSTIC SERVICES $0 80% 20% $0 100% $0 $0 HD This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $2,180 deductible. Benefits from the High Deductible Plan F will not begin until out-of-pocket expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. NOTE: You may move to Wellmark s regular Plan F from High Deductible Plan F without answering health questions after twelve consecutive months of enrollment on High Deductible Plan F. You may only move during the Annual Enrollment Period, Oct. 15 Dec. 7, for a Jan. 1 effective date. Medicare Parts A & B Services Home Health Care MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Medicare Pays After you pay $2,180 deductible Plan F HD Pays 100% $0 $0 Durable medical equipment: First $147 of Medicare approved $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Other Benefits Not Covered by Medicare Services Foreign Travel NOT COVERED BY MEDICARE 80% 20% $0 Medicare Pays After you pay $2,180 deductible Plan F HD Pays You Pay $0 You Pay Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 HD This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $2,180 deductible. Benefits from the High Deductible Plan F will not begin until out-ofpocket expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 20% and amounts over the $50,000 lifetime maximum 18 19

16 MedicareBlue Supplement Plan N Medicare (Part A) Hospital Services Per Benefit Period Services Medicare Pays Plan N Pays You Pay Hospitalization 1 Semiprivate room and board, general nursing and miscellaneous services and supplies. First 60 days All but $1,260 $1,260 (Part A deductible) 61st thru 90th day All but $315 a day $315 a day $0 91st day and after While using 60 lifetime reserve days All but $630 a day $630 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare eligible expenses Beyond the additional 365 days $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st thru 100th day All but $ a day Up to $ a day $0 101st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 Hospice Care You must meet Medicare s requirements, including doctor s certification of terminal illness. All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance 1 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. $0 $0 2 $0 Medicare (Part B) Medical Services Per Calendar Year Services Medicare Pays Plan N 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 $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Part B Excess Charges (Above Medicare approved amounts) Blood Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. $0 $0 All costs First 3 pints $0 All costs $0 Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Next $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Clinical Laboratory Services TESTS FOR DIAGNOSTIC SERVICES 80% 20% $0 100% $0 $0 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. 2 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 Basic 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

17 MedicareBlue Supplement Plan N (continued) Medicare Parts A & B Services Medicare Pays Plan N Pays You Pay Home Health Care MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment: First $147 of Medicare approved $0 $0 $147 amounts 3 (Part B deductible) Remainder of Medicare approved amounts Other Benefits Not Covered by Medicare 80% 20% $0 Services Medicare Pays Plan N Pays You Pay 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year. Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. 20% and amounts over the $50,000 lifetime maximum Premium payments may be made on a calendar month, calendar quarter, semi-annual calendar year, or calendar year basis. For example, a monthly premium would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual premium would be for January 1 through December 31 of the applicable year. The amount of your periodic premium payment will change as provided in the policy and from time to time based on changes in your coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), your age, or other factors that require adjustments to the total premium. These changes may occur at times other than an annual or other policy renewal. If you elected to authorize automatic premium withdrawals from a deposit account, the automatic withdrawal will change periodically to correspond with the applicable premium. Your authorization for automatic premium withdrawals shall include authorization for automatic withdrawal of any changed amount unless you call or provide your bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If you call your bank to stop payment, you may be required to provide a written request within fourteen (14) days after your call. You will be responsible for any fee assessed by your bank for stop-payment orders that you make. MedicareBlue Supplement SM is a Medicare Supplement insurance plan. MedicareBlue Supplement SM is not connected with or endorsed by the U.S. government or the federal Medicare program

18 If you have questions or need additional information, call toll-free Not Enrolled: Already Enrolled: TTY hearing impaired users call 711 Wellmark Blue Cross and Blue Shield of Iowa is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross, Blue Shield, and the Cross and Shield Symbols are registered marks, and MedicareBlue Supplement SM is a service mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark is a registered mark of Wellmark, Inc Wellmark, Inc. M /14

19 Application for MedicareBlue Supplement SM A. Tell us about yourself. Applicant Name (First, Middle, Last) Requested Effective Date / / Date of Birth (mm/dd/yyyy) / / Daytime Phone ( ) Gender c Male c Female Address (optional) Social Security Number Address Information: Physical Address (Include Street, Bldg Name/No., Apt. No.) County Name City State Zip If mailing address is NOT the same as the physical address listed above, please complete mailing address information. Mailing Address (Include Street, Bldg Name/No., Apt. No.) PO Box City State Zip B. Tell us about your tobacco usage. Note: You are required to answer this question. However, if you are applying during a guaranteed issue rights period or during your six-month Medicare Supplement open enrollment period only the Non-Tobacco user premium will apply. c Yes c No B1. Have you used tobacco during the 12 months immediately preceding the effective date of this application? C. Provide us with your Medicare information. Please take out your Medicare ID card and use it to assist you in completing this section of the application. Fill in the blank spaces so they match your red, white, and blue Medicare ID card exactly. Name: Medicare Number: Sex (M/F): - - Is Entitled to: Effective Date (mm/dd/yyyy): HOSPITAL (Part A) / / MEDICAL (Part B) / / M /13 Page 1 of 11

20 Applicant Name (First, Middle, Last) Social Security Number C. Provide us with your Medicare information, cont d. c Yes c No c Yes c No c Yes c No C1. Did you turn age 65 in the last 6 months? C2. Did you enroll in Medicare Part B in the last 6 months? If yes, what is your Part B effective date (mm/dd/yyyy)? / / C3. Are you applying for a plan effective date within 6 months after: your Medicare Part B effective date and turning 65 (or older)? or the first day of the month in which you turn age 65 (or the first day of the month prior to the month in which you turn age 65 if your birth date is the first day of the month) and are currently enrolled in Medicare Part B? STOP If you answered YES to question C3 above, you are within your Medicare Supplement Open Enrollment Period and your acceptance is guaranteed. You do not have to answer health questions and can proceed to Section G of the application to select your plan. You are eligible for Plans A, D, F, High Deductible F and N. To determine your monthly premium amount, refer to the MedicareBlue Supplement - Preferred Non-Tobacco premium table in the Outline of Coverage for Plans D, F, High Deductible F and N, and to the MedicareBlue Supplement - Standard Non-Tobacco premium table in the Outline of Coverage for Plan A. If you answered NO to question C3 above, please continue to Section D to determine if your acceptance is guaranteed. D. Review the following loss of coverage situations to determine if your acceptance is guaranteed. If your previous coverage terminated or ceased to provide some benefits more than 63 days prior to the date of this application, you are outside of your guaranteed issue rights period. You must complete the entire application including answering the health questions. Please go to Section E to determine the plan(s) for which you are eligible. If you lost or are losing other health insurance coverage and received a notice from your previous insurer and/or employer saying that you are eligible for guaranteed issue of a Medicare Supplement insurance policy, or that you have certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare Supplement plans. If one of these situations applies to you, check the appropriate box at the left and then provide the date your coverage was effective and/or the date your coverage will end (mm/dd/yyyy). Check one only. c Applies to me D1. I am enrolled in a Medicare Advantage Plan, and my plan is leaving Medicare or will no longer be providing coverage in my area, or I have moved out of my plan s service area. If applicable, please provide the date coverage will end / / M /13 Page 2 of 11

21 Applicant Name (First, Middle, Last) Social Security Number D. Review the following loss of coverage situations to determine if your acceptance is guaranteed, cont d. c Applies to me c Applies to me c Applies to me c Applies to me c Applies to me c Applies to me D2. I have Original Medicare and an employer group health plan that pays after Medicare pays and that plan has stopped providing some or all health benefits (only applies to involuntary loss of coverage). If this applies to you, check the option that describes your situation below: a. Retiree coverage is being terminated by the employer b. COBRA eligibility has expired c. Group coverage with under 20 employees is ending d. After 30 months of coverage for end stage renal disease If applicable, please provide the date coverage will end / / D3. I have Original Medicare and a Medicare Select policy, and I am moving out of the Medicare Select policy s service area. If applicable, please provide the date coverage will end / / D4. I joined a Medicare Advantage Plan or Programs for All-Inclusive Care for the Elderly (PACE) when I was first eligible for Medicare Part A or B at age 65, and within the first year of joining, I want to disenroll. (Trial Right) If applicable, please provide the date coverage was effective / / ; and the date coverage will end / / D5. I canceled my Medicare Supplement policy to join a Medicare Advantage Plan (or to switch to a Medicare Select policy) for the first time, have been in the plan less than one year, and want to re-enroll in my original Medicare Supplement policy or my original Medicare Supplement policy is no longer available. (Trial Right). If applicable, please provide the date coverage was effective / / ; and the date coverage will end / / D6. I have Medicare Supplement insurance, and I am losing my coverage because the insurance company went bankrupt, or my coverage is ending through no fault of my own. If applicable, please provide the date coverage will end / / D7. I am leaving a Medicare Advantage Plan or a Medicare Supplement policy because I have been notified the insurance company has violated a provision of its contract with me or it misled me. If applicable, please provide the date coverage will end / / STOP If you checked any of the situations above and your coverage did not end (or cease to provide some benefits) more than 63 days before the date of this application, your acceptance may be guaranteed. You do not have to answer health questions and can proceed to Section G of the application to select your plan. You are eligible for Plans A, D, F, High Deductible F and N. To determine your monthly premium amount, refer to the MedicareBlue Supplement - Preferred Non-Tobacco premium table in the Outline of Coverage for Plans D, F, High Deductible F and N, and to the MedicareBlue Supplement - Standard Non-Tobacco premium table in the Outline of Coverage for Plan A. If none of the situations above apply to you, you must complete the entire application including answering the health questions. Please continue to Section E to determine the plan(s) for which you are eligible. M /13 Page 3 of 11