Senior Blue. Medicare Supplement Coverage M-51570 10/05

Senior Blue Medicare Supplement Coverage M-51570 10/05

Senior Blue... Iowa s Choice Since 1939, Wellmark Blue Cross and Blue Shield of Iowa has been providing quality health insurance to the people of Iowa. We re known for our experience, reliability and dedication to Iowans. That s why so many Iowans choose Wellmark Blue Cross and Blue Shield for their Medicare Supplement coverage. Senior Blue A Step Ahead Senior Blue Medicare Supplement plans help pay for health care expenses that aren t covered by Medicare. There are deductible, copayment and coinsurance gaps in Medicare coverage that can quickly add up. With Wellmark Blue Cross and Blue Shield of Iowa, you have access to flexible, affordable plans that help pay for these Medicare gaps. With Senior Blue, you ll receive: Stability and security Wellmark Blue Cross and Blue Shield of Iowa is known for financial strength. We received an A (Excellent) rating from A.M. Best Company 1 and an A+ (Strong) rating from Standard & Poor s. 2 Personal customer service We have an entire customer service unit devoted just to helping our Senior Blue members. You can count on us for friendly, courteous service. Worldwide acceptance Your Senior Blue coverage follows you anywhere in the United States. When you select Plan C, E, or F, you even receive emergency coverage outside of the United States. When you enroll in Senior Blue, you re automatically a member of our Blue Plus Club. SM This club offers special discounts on items like prescription drugs, vision services, hearing equipment, fitness club memberships and more! 1 A.M. Best Company, July 2005 2 Standard & Poor s, July 2005 1

Coverage Without the Hassle Insurance doesn t have to be complicated. That s why we invite you to check out our Senior Blue Medicare Supplement plans. Provider Choice You can receive services from any physician, hospital or medical facility. You may want to receive care from providers who participate with Medicare since they agree to accept Medicare-approved amounts as full payment on Medicare claims, except for applicable deductibles and copayments. No Waiting Periods There are no waiting periods, even if you have existing health problems. With Senior Blue, you are covered immediately on the date your policy begins. No Medical Exams Applying for Senior Blue coverage is quick and easy. We won t ask you to complete a medical exam or answer pages of questions. Your acceptance is based upon yes and no answers to three or four simple health questions. If you enroll during your six-month guaranteed enrollment period, 3 or if you apply for Plan A or guaranteed-issue Plan C, you don t even have to answer any health questions. No Claim Forms Tired of filling out claim forms? Then Senior Blue is for you. With Senior Blue, those days of worrying about confusing claim forms or keeping track of paperwork are over. Simply present your Senior Blue identification card when you visit your local doctor s office or other medical facility. Your provider will file your claim automatically for you. Guaranteed Renewable Coverage As long as you pay your premiums when due, your coverage is guaranteed. We will not cancel your policy even if you develop health problems. 3 Acceptance is guaranteed during the six-month guaranteed enrollment period which begins the first day of the first month you are age 65 or older and enrolled in Medicare Part B (medical insurance). 2

Senior Blue Plan Benefits Medicare Supplement plan benefits do not vary between insurance companies. We offer five standardized plans. Senior Blue can help you pay for deductibles, copayments and some services not covered by Medicare. We Offer 5 Standard Medicare Supplement Plans Plan A is our most economical coverage. It provides basic benefits, including Medicare s Part A hospital and Part B medical co-payments, and your first three pints of blood each year. Plan C covers the basic benefits just described, plus Medicare s Part A and Part B deductibles, skilled nursing copayments and foreign travel emergencies. Plan E includes many of the same benefits as Plan C, but also covers preventive care not covered by Medicare. This includes some annual physical and preventive tests and services ordered by your physician when not covered by Medicare. Plan F is our most popular plan. It also includes the same benefits as Plan C, plus it provides benefits for the difference between what the doctor charges and what Medicare approves (this is important if your physician charges more than Medicare s eligible expense). 3

Plan L offers most of the same benefits as Plans A, C, E and F, but is designed to offer lower monthly premiums, which means certain copayments are higher so you may pay a greater share of some costs. There are also set limits to your out-of-pocket costs in any given year. Use this chart to determine which plan best meets your needs. Items Not Covered by Medicare Part A Hospital Services Covered by Senior Blue A C E F L Part A Deductible (75%) Copayment for days 61-90 in a hospital Copayment for days 91-150 in a hospital 100% of Medicare-allowable expenses for additional 365 days after Medicare hospital benefits stop completely Calendar year blood deductible (first 3 pints of blood)if the deductible (75%) is not met by the replacement of blood Copayment for 21-100 days in a skilled nursing facility (75%) Part B Physician and Medical Services $124.00 Part B deductible 20% of Medicare-approved amount after $124.00 Part B deductible is met (75%) 100% of Medicare Part B excess charges Additional Benefits Not Covered by Medicare First $124.00 of Medicare-approved amounts for Durable Medical Equipment Benefits for medically necessary emergency care received in a foreign country Out-of-Pocket Annual Limit ($2,000) Please refer to your Senior Blue Outline of Coverage for additional information. 4

Blue Plus Club SM Discounts & Services Helping you stay healthy is important to us. That s why we offer programs and services to make it easier for you to take an active role in your overall well-being. As a Senior Blue Medicare Supplement member, you are eligible to participate in our Blue Plus Club, which gives you access to a variety of discounts and services, at no additional cost, that are designed to help you stretch your health care dollars. The Blue Plus Club includes: WellScript Prescription Drug Discount Program Vision exams, eyewear, laser surgery Hearing exams and hearing aids Complementary medicine including chiropractic, acupuncture, massage therapy, dietetic counseling and others Vitamin supplements and other natural products Cosmetic surgery Durable Medical Equipment Accidental Death & Dismemberment coverage Blue Plus Club You ll Be Glad You re A Member The Blue Plus Club program is designed to save you time so that you can enjoy yourself. Be sure to read the Blue Plus Club brochure to learn step-by-step how to use each element of the core program. We ve tried to cover all of the bases, but if you still have questions, you can call the vendor phone numbers listed in the brochure. 5

How to Apply for Senior Blue Applying for Senior Blue is easy and won t take much time. If you have questions regarding the enrollment process, call us at 1-800-336-0505, or contact your local authorized Wellmark Blue Cross and Blue Shield of Iowa agent. Eligibility Requirements To enroll in Senior Blue, you must: Be a resident of Iowa; Be enrolled in Medicare Part A and Part B; and Not be covered by another Medicare supplement policy at the time this policy is issued, unless you intend to replace your other policy. Choose Your Senior Blue Plan Please read the Senior Blue Outline of Coverage carefully. It s included with this brochure. Determine which of the five plans A, C, E, F or L is best for you. Calculate your monthly premium using the table in the Outline of Coverage. The premiums are shown by age category and benefit plan. Easy Payment Options 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. You may choose to have your payments automatically withdrawn from your checking or savings account. If you want premiums automatically withdrawn from your account, attach a voided check to the application. Ask your insurance agent or Wellmark representative if it s necessary for you to send a payment with your application. * The monthly payment option is available only when premiums are automatically withdrawn from your checking or savings account. 6

Submit Your Enrollment Materials Complete, sign, and mail the following items to us. Application Form Please use an ink pen to complete the application. Keep the last copy for your records. Notice to Applicant Regarding Replacement of Medicare Supplement Insurance (white copy) Return this form only if you are replacing a current Medicare supplement policy with a Senior Blue policy. A few tips to ensure Prompt and Accurate Claims Filing Promptly and Accurately That's how you want your health care claims processed. And that s what you get when you have a Senior Blue Medicare Supplement plan from Wellmark Blue Cross and Blue Shield of Iowa. Filing Medicare Claims First Federal regulations require that all health care providers fill out and submit Medicare claim forms to the Medicare office serving the state where the services are performed. You don't have to do anything. Medicare Supplement Benefits We will process your claim for Medicare Supplement benefits when we receive an Explanation of Medicare Benefits (EOMB) from the Medicare office. How that EOMB gets to us depends on where you receive the services. Here are a few tips about filing, so you can help us help you Iowa Providers Since you are a Wellmark Blue Cross and Blue Shield of Iowa member, your EOMB is automatically transferred from Medicare to us, in most cases. When your doctor, clinic, hospital or other provider is in the state of Iowa, you do not have to do anything. The Medicare office in Iowa sends your claim directly to Wellmark. Once we have processed your claim, you will receive an Explanation of Benefits (EOB) from us. 7

The EOB shows what amount was paid by Medicare, what amount was paid by us, and the balance due, if any. Providers Outside of Iowa If you receive health care services when you are in another state, the provider will submit your Medicare claim to the Medicare office in the state where you receive services. Some out-of-state Medicare offices do not transfer the claim to us. Once a claim is processed by a Medicare office in another state, you will receive an EOMB. Examine the section of the EOMB marked Notes. You may find a message stating: This information is being sent to your private insurer. If this message is present, your EOMB will be sent to us automatically. If there is no message like this, you need to send the EOMB to us so we can process your Medicare supplement benefits. You do not need to complete a claim form, just send us the EOMB. Before you send the EOMB to us, be sure that your Wellmark Blue Cross and Blue Shield of Iowa identification number and mailing address is shown accurately on the EOMB form. Please remember, you may want to keep a copy of the EOMB for your own records. 8

Friendly, Efficient Customer Service You can count on friendly, efficient customer service from Wellmark Blue Cross and Blue Shield of Iowa customer service centers. Whenever you call one of our customer service centers, you can help us better serve you. Have your identification (ID) number ready because that's one of the first questions your customer service representative will ask you. We'll also need to verify your date of birth and home address. If you are calling about a claim or another document, have that document available so you can refer to it as you talk with your customer service representative. Whatever your reason for calling on us, you'll talk with someone who cares about your questions and is professionally trained to help you. 9

Call Toll Free: 1-800-245-6106 TTY/TDD users should call 1-888-781-4262 or 515-235-4212 OR Contact one of these Wellmark Blue Cross and Blue Shield of Iowa Customer Service Centers: Cedar Rapids 625 First Street S.E., Suite 150 Cedar Rapids, IA 52401 319-294-5933 800-373-5348 Des Moines 601 Locust Street 2nd Floor Des Moines, IA 50309 800-245-6106 Other important numbers you may need: Medicare Part A and Part B 1-800-MEDICARE (633-4227) TTY/TDD users should call 1-887-486-2048 Social Security Administration 1-800-772-1213 TTY/TDD users should call 1-800-325-0778 Senior Health Insurance Information Program (SHIIP) 1-800-351-4664 10

Wellmark Blue Cross and Blue Shield of Iowa is an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross, Blue Shield, the Cross and Shield symbols, Senior Blue, and You Just Can t Beat The Blues are registered marks and Blue Plus Club SM and Blue Rx SM are service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. Wellmark and WellScript are registered marks of Wellmark, Inc.