BlueEliteSM

Outline of Medicare Supplement Coverage Benefits Plans A, B, C, D, F, G, K, L, M and N*

* BlueCross BlueShield of Tennessee only offers Plans A, C, D, F, G and N.

Benefit Chart of Medicare Supplement Plans Sold On or After January 1, 2020

This chart shows the benefits included in each of the standard Medicare Supplement plans. Some plans may not be available. Only applicants who were first (1st) eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.

Medicare First Eligible Before

Plans Available to All Applicants 2020 only Benefits A B D G1 K L M N

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Medicare Part B coinsurance or copayment ✔ ✔ ✔ ✔ 50% 75% ✔

✔

copays apply3

Blood (first three pints) ✔ ✔ ✔ ✔ 50% 75% ✔ ✔

Part A hospice care coinsurance or copayment ✔ ✔ ✔ ✔ 50% 75% ✔ ✔

Skilled nursing facility coinsurance ✔ ✔ 50% 75% ✔ ✔

Medicare Part A deductible ✔ ✔ ✔ 50% 75% 50% ✔

Medicare Part B deductible

Medicare Part B excess charges ✔

Foreign travel emergency (up to plan limits) ✔ ✔ ✔ ✔

Out-of-pocket limit in 20202 $5,8802 $2,9402

C F1

✔ ✔

✔ ✔

✔ ✔

✔ ✔

✔ ✔

✔ ✔

✔ ✔

✔

✔ ✔

1 Plans F and G also have a high deductible option which require first paying a plan deductible of $2,340 before the plan begins to pay. Once the plan deductible is met, the plan pays one hundred percent (100%) of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2 Plans K and L pay one hundred percent (100%) of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 Plan N pays one hundred percent (100%) of the Part B coinsurance, except for a co-payment of up to twenty dollars ($20) for some office visits and up to a fifty

dollar ($50) co-payment for emergency room visits that do not result in an inpatient admission.

123776_20_OCR1 (3/20)

BlueElite Monthly Premiums Effective 6/1/2020 Premiums may be subject to change.1

Female Non-Tobacco2

Attained Age Plan A Plan C Plan D Plan F Plan G Plan N

65 $67.83 $138.38 $114.50 $145.07 $108.35 $103.06 66 $72.35 $147.60 $122.13 $154.73 $108.35 $109.92 67 $77.17 $157.43 $130.26 $165.03 $108.35 $117.24 68 $82.01 $167.33 $138.45 $175.41 $108.35 $124.62 69 $86.88 $177.21 $146.61 $185.77 $114.76 $131.95 70 $91.73 $187.13 $154.88 $196.17 $121.17 $139.39 71 $96.55 $197.03 $163.05 $206.55 $127.59 $146.74 72 $101.42 $206.89 $171.21 $216.89 $133.97 $154.09 73 $106.22 $216.72 $179.39 $227.19 $140.33 $161.45 74 $111.09 $226.69 $187.58 $237.64 $146.79 $168.82 75 $115.39 $235.45 $194.85 $246.83 $152.46 $175.36 76 $120.78 $246.42 $203.89 $258.32 $159.56 $183.50 77 $125.63 $256.33 $212.11 $268.72 $165.99 $190.90 78 $130.10 $265.40 $219.61 $278.22 $171.86 $197.65 79 $134.16 $273.75 $226.56 $286.97 $177.26 $203.91 80 $137.94 $281.50 $232.92 $295.09 $182.28 $209.63 81 $141.54 $288.73 $238.92 $302.68 $186.96 $215.03 82 $144.83 $295.49 $244.51 $309.77 $191.34 $220.06 83 $147.97 $301.84 $249.80 $316.41 $195.45 $224.82 84 $150.84 $307.86 $254.74 $322.74 $199.35 $229.27 85 $153.68 $313.52 $259.45 $328.67 $203.02 $233.50 86 $156.29 $318.76 $263.92 $334.16 $206.41 $237.52 87 $158.80 $324.03 $268.15 $339.68 $209.82 $241.33 88 $161.19 $328.94 $272.22 $344.82 $212.99 $245.00 89 $163.51 $333.60 $276.05 $349.73 $216.03 $248.44 90 $165.72 $338.08 $279.75 $354.41 $218.92 $251.78 91 $167.79 $342.37 $283.33 $358.90 $221.70 $254.99

Under 653 $671.49 $1,235.10 $1,133.58 $1,294.76 $1,208.89 $1,020.23

1 Monthly premiums will increase by 10% for enrollees who move outside of the state of Tennessee.

2 This chart shows monthly premiums for BlueElite Medicare Supplement plans when applying during a Guaranteed Issue Period or Medigap Open Enrollment Period.

3 Eligible for and enrolled in Medicare by reason of disability or end stage renal disease.

2

BlueElite Monthly Premiums Effective 6/1/2020 Premiums may be subject to change.1

Male Non-Tobacco2

Attained Age Plan A Plan C Plan D Plan F Plan G Plan N

65 $73.73 $150.42 $124.48 $157.69 $117.79 $112.03 66 $78.62 $160.44 $132.76 $168.19 $117.79 $119.49 67 $83.86 $171.12 $141.60 $179.39 $117.79 $127.45 68 $89.15 $181.89 $150.51 $190.68 $117.79 $135.45 69 $94.45 $192.61 $159.39 $201.92 $124.74 $143.45 70 $99.70 $203.42 $168.36 $213.25 $131.72 $151.53 71 $104.95 $214.18 $177.23 $224.53 $138.70 $159.51 72 $110.25 $224.91 $186.10 $235.78 $145.64 $167.50 73 $115.46 $235.59 $195.00 $246.97 $152.56 $175.50 74 $120.77 $246.41 $203.90 $258.31 $159.57 $183.51 75 $125.42 $255.94 $211.80 $268.31 $165.73 $190.62 76 $131.28 $267.86 $221.64 $280.80 $173.45 $199.47 77 $136.55 $278.64 $230.58 $292.10 $180.43 $207.52 78 $141.43 $288.49 $238.73 $302.43 $186.82 $214.85 79 $145.84 $297.57 $246.27 $311.95 $192.70 $221.65 80 $149.96 $305.98 $253.19 $320.77 $198.15 $227.87 81 $153.86 $313.85 $259.71 $329.01 $203.24 $233.74 82 $157.43 $321.21 $265.78 $336.72 $208.01 $239.20 83 $160.83 $328.11 $271.53 $343.95 $212.47 $244.38 84 $163.97 $334.65 $276.90 $350.82 $216.71 $249.21 85 $167.05 $340.79 $282.01 $357.26 $220.69 $253.81 86 $169.89 $346.48 $286.87 $363.22 $224.38 $258.19 87 $172.63 $352.22 $291.48 $369.23 $228.09 $262.33 88 $175.22 $357.54 $295.91 $374.82 $231.54 $266.31 89 $177.76 $362.64 $300.07 $380.16 $234.83 $270.06 90 $180.16 $367.51 $304.11 $385.27 $237.98 $273.70 91 $182.40 $372.17 $307.97 $390.15 $241.00 $277.17

Under 653 $729.92 $1,342.61 $1,232.22 $1,407.48 $1,314.13 $1,109.00

1 Monthly premiums will increase by 10% for enrollees who move outside of the state of Tennessee.

2 This chart shows monthly premiums for BlueElite Medicare Supplement plans when applying during a Guaranteed Issue Period or Medigap Open Enrollment Period.

3 Eligible for and enrolled in Medicare by reason of disability or end stage renal disease.

3

BlueElite Monthly Premiums Effective 6/1/2020 Premiums may be subject to change.1

Female Tobacco User

Attained Age Plan A Plan C Plan D Plan F Plan G Plan N

65 $74.61 $152.22 $125.95 $159.58 $119.19 $113.37 66 $79.59 $162.36 $134.34 $170.20 $119.19 $120.91 67 $84.89 $173.17 $143.29 $181.53 $119.19 $128.96 68 $90.21 $184.06 $152.30 $192.95 $119.19 $137.08 69 $95.57 $194.93 $161.27 $204.35 $126.24 $145.15 70 $100.90 $205.84 $170.37 $215.79 $133.29 $153.33 71 $106.21 $216.73 $179.36 $227.21 $140.35 $161.41 72 $111.56 $227.58 $188.33 $238.58 $147.37 $169.50 73 $116.84 $238.39 $197.33 $249.91 $154.36 $177.60 74 $122.20 $249.36 $206.34 $261.40 $161.47 $185.70 75 $126.93 $259.00 $214.34 $271.51 $167.71 $192.90 76 $132.86 $271.06 $224.28 $284.15 $175.52 $201.85 77 $138.19 $281.96 $233.32 $295.59 $182.59 $209.99 78 $143.11 $291.94 $241.57 $306.04 $189.05 $217.42 79 $147.58 $301.13 $249.22 $315.67 $194.99 $224.30 80 $151.73 $309.65 $256.21 $324.60 $200.51 $230.59 81 $155.69 $317.60 $262.81 $332.95 $205.66 $236.53 82 $159.31 $325.04 $268.96 $340.75 $210.47 $242.07 83 $162.77 $332.02 $274.78 $348.05 $215.00 $247.30 84 $165.92 $338.65 $280.21 $355.01 $219.29 $252.20 85 $169.05 $344.87 $285.40 $361.54 $223.32 $256.85 86 $171.92 $350.64 $290.31 $367.58 $227.05 $261.27 87 $174.68 $356.43 $294.97 $373.65 $230.80 $265.46 88 $177.31 $361.83 $299.44 $379.30 $234.29 $269.50 89 $179.86 $366.96 $303.66 $384.70 $237.63 $273.28 90 $182.29 $371.89 $307.73 $389.85 $240.81 $276.96 91 $184.57 $376.61 $311.66 $394.79 $243.87 $280.49

Under 652 $738.64 $1,358.61 $1,246.94 $1,424.24 $1,329.78 $1,122.25

1 Monthly premiums will increase by 10% for enrollees who move outside of the state of Tennessee.

2 Eligible for and enrolled in Medicare by reason of disability or end stage renal disease.

4

BlueElite Monthly Premiums Effective 6/1/2020 Premiums may be subject to change.1

Male Tobacco User

Attained Age Plan A Plan C Plan D Plan F Plan G Plan N

65 $81.10 $165.46 $136.93 $173.46 $129.57 $123.23 66 $86.48 $176.48 $146.04 $185.01 $129.57 $131.44 67 $92.25 $188.23 $155.76 $197.33 $129.57 $140.20 68 $98.07 $200.08 $165.56 $209.75 $129.57 $149.00 69 $103.90 $211.87 $175.33 $222.11 $137.21 $157.80 70 $109.67 $223.76 $185.20 $234.58 $144.89 $166.68 71 $115.45 $235.60 $194.95 $246.98 $152.57 $175.46 72 $121.28 $247.40 $204.71 $259.36 $160.20 $184.25 73 $127.01 $259.15 $214.50 $271.67 $167.82 $193.05 74 $132.85 $271.05 $224.29 $284.14 $175.53 $201.86 75 $137.96 $281.53 $232.98 $295.14 $182.30 $209.68 76 $144.41 $294.65 $243.80 $308.88 $190.80 $219.42 77 $150.21 $306.50 $253.64 $321.31 $198.47 $228.27 78 $155.57 $317.34 $262.60 $332.67 $205.50 $236.34 79 $160.42 $327.33 $270.90 $343.15 $211.97 $243.82 80 $164.96 $336.58 $278.51 $352.85 $217.97 $250.66 81 $169.25 $345.24 $285.68 $361.91 $223.56 $257.11 82 $173.17 $353.33 $292.36 $370.39 $228.81 $263.12 83 $176.91 $360.92 $298.68 $378.35 $233.72 $268.82 84 $180.37 $368.12 $304.59 $385.90 $238.38 $274.13 85 $183.76 $374.87 $310.21 $392.99 $242.76 $279.19 86 $186.88 $381.13 $315.56 $399.54 $246.82 $284.01 87 $189.89 $387.44 $320.63 $406.15 $250.90 $288.56 88 $192.74 $393.29 $325.50 $412.30 $254.69 $292.94 89 $195.54 $398.90 $330.08 $418.18 $258.31 $297.07 90 $198.18 $404.26 $334.52 $423.80 $261.78 $301.07 91 $200.64 $409.39 $338.77 $429.17 $265.10 $304.89

Under 652 $802.91 $1,476.87 $1,355.44 $1,548.23 $1,445.54 $1,219.90

1 Monthly premiums will increase by 10% for enrollees who move outside of the state of Tennessee.

2 Eligible for and enrolled in Medicare by reason of disability or end stage renal disease.

5

 

PREMIUM INFORMATION BlueCross BlueShield of Tennessee can only raise your premium if we raise the premium for all policies like yours in the state of Tennessee. Your premium rate is based on your age as of June 1 each year, and it increases annually as you move into the next age category. If you are not yet 65 but will be on your initial effective date, your premium rate will be the age 65 rate. If you are over 65 and enrolling or changing plans, your premium rate is based on your age as of June 1 on or before your initial effective date. Your rate will increase by 10% if you move outside the state of Tennessee. Other than for age or moving out of the state, BlueCross BlueShield of Tennessee will only adjust your rate if rates are adjusted for all policies like yours. Any rate adjustment will be made at the same time for all BlueElite customers who have the same policy.

DISCLOSURES Use this outline to compare benefits and premiums among policies.

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 the rights and duties of both you and BlueCross BlueShield of Tennessee.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to:

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402

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 (less any benefits provided).

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 BlueCross BlueShield of Tennessee 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 the Medicare and You Handbook 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. BlueCross BlueShield of Tennessee 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.

CREDITABLE COVERAGE Medical coverage that may include a workplace health plan, COBRA, a federal government plan (including TRICARE, CHAMPUS, CHAMPUSVA), church plan coverage or an individual health or Medicare Supplement plan.

Your previous health coverage must not have been canceled voluntarily or for fraud or non-payment of premiums. You must not have had more than a 63-day gap between the date the other coverage(s) ended and the effective date of your new Medicare Supplement plan.

GUARANTEED ISSUE PERIOD The 63-day period following certain situations in which you have involuntarily lost prior health care coverage. Examples include: moving out of plan service area or losing group health care coverage. For a complete list of situations, refer to the “Choosing a Medigap Policy” booklet.

PRE-EXISTING CONDITIONS A condition is considered pre-existing if medical advice was given or treatment recommended by or received from a provider within six months prior to the insurance effective date. All or part of this six month pre-existing condition waiting period can be waived if you have creditable coverage.

LIMITATIONS AND EXCLUSIONS Unless otherwise specifically noted in your policy, BlueCross BlueShield of Tennessee Medicare Supplement plans do not provide benefits for any of the following:

� Services and supplies not covered by Medicare, except those specifically included under the plan you select.

� Any expense that is paid by Medicare.

� Hospital stays beginning or medical expenses incurred during the first six months of coverage if they are caused by what is considered a pre-existing condition. A condition is considered pre-existing if medical advice was given or treatment recommended by or received from a physician within six months prior to the insurance effective date. All or part of this six-month pre-existing condition waiting period can be waived if you have creditable coverage.

6

* A benefit period begins on the first day you receive service as an inpatient in a hospital and Plan A Medicare (Part A) ends after you have been out of the hospital and

Hospital Services – Per Benefit Period have not received skilled care in any other facility for 60 days in a row. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Hospitalization* Semi-private room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $0 $1,408 (Part A deductible)

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:

While using 60 lifetime reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare -eligible expenses $0**

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $176 a day $0 Up to $176 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 a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/ coinsurance $0

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

7

Services Medicare Pays Plan Pays You Pay

Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (Above Medicare-approved amounts)

$0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% $0 $0

* Once you have been billed $198 of Medicare-Plan A Medicare (Part B) approved amounts for covered services (which are noted with an asterisk), your Part B deductible

Medical Services – Per Calendar Year will have been met for the calendar year. Amounts below are based on Medicare’s 2020 cost-share.

Plan A Medicare (Parts A&B)

Services Medicare Pays Plan Pays You Pay

Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies

100% $0 $0

Durable Medical Equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

8

* A benefit period begins on the first day you receive service as an inpatient in a hospital and Plan C Medicare (Part A) ends after you have been out of the hospital and

Hospital Services – Per Benefit Period have not received skilled care in any other facility for 60 days in a row. Amounts below are based on Medicare’s 2020 cost-share.

Only available to applicants first eligible for Medicare before January 1, 2020.

Services Medicare Pays Plan Pays You Pay

Hospitalization* Semi-private room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:

While using 60 lifetime reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare -eligible expenses $0**

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $176 a day Up to $176 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 a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/ coinsurance $0

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

9

* Once you have been billed $198 of Medicare-Plan C Medicare (Part B) approved amounts for covered services (which are noted with an asterisk), your Part B deductible

Medical Services – Per Calendar Year will have been met for the calendar year. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (Above Medicare-approved amounts)

$0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% 0% 0%

10

* Once you have been billed $198 of Medicare-approved amounts for covered services (which Plan C Medicare (Parts A&B) are noted with an asterisk), your Part B deductible

Amounts below are based on Medicare’s 2020 cost-share. will have been met for the calendar year.

Services Medicare Pays Plan Pays You Pay

Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies

100% $0 $0

Durable Medical Equipment

First $198 of Medicare-approved amounts* $0 $198

(Part B deductible) $0

Remainder of Medicare-approved amounts 80% 20% $0

Other Benefits – Not Covered by Medicare

Services Medicare Pays Plan 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

20% and amounts over the $50,000 lifetime

maximum

11

* A benefit period begins on the first day you Plan D Medicare (Part A) receive service as an inpatient in a hospital and ends after you have been out of the hospital and

Hospital Services – Per Benefit Period have not received skilled care in any other facility Amounts below are based on Medicare’s 2020 cost-share. for 60 days in a row.

Services Medicare Pays Plan Pays You Pay

Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:

While using 60 lifetime reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare -eligible expenses $0**

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $176 a day Up to $176 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 a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/ coinsurance $0

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

12

* Once you have been billed $198 of Medicare-approved amounts for covered services (which Plan D Medicare (Part B) are noted with an asterisk), your Part B deductible

Medical Services – Per Calendar Year will have been met for the calendar year. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (Above Medicare-approved amounts)

$0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% 0% 0%

13

* Once you have been billed $198 of Medicare-Plan D Medicare (Parts A&B) approved amounts for covered services (which are noted with an asterisk), your Part B deductible

Amounts below are based on Medicare’s 2020 cost-share. will have been met for the calendar year.

Services Medicare Pays Plan Pays You Pay

Home Health Care Medicare Approved Services Medically necessary skilled care services and medical supplies

100% $0 $0

Durable Medical Equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Other Benefits – Not Covered by Medicare

Services Medicare Pays Plan 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

20% and amounts over the $50,000 lifetime

maximum

14

* A benefit period begins on the first day you receive service as an inpatient in a hospital and Plan F Medicare (Part A) ends after you have been out of the hospital and

Hospital Services – Per Benefit Period have not received skilled care in any other facility for 60 days in a row. Amounts below are based on Medicare’s 2020 cost-share.

Only available to applicants first eligible for Medicare before January 1, 2020.

Services Medicare Pays Plan Pays You Pay

Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:

While using 60 lifetime reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare -eligible expenses $0**

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $176 a day Up to $176 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 a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/ coinsurance $0

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

15

* Once you have been billed $198 of Medicare-Plan F Medicare (Part B) approved amounts for covered services (which are noted with an asterisk), your Part B deductible

Medical Services – Per Calendar Year will have been met for the calendar year. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (Above Medicare-approved amounts)

$0 100% $0

Blood

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $198 (Part B deductible) $0

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% 0% 0%

16

* Once you have been billed $198 of Medicare-approved amounts for covered services (which Plan F Medicare (Parts A&B) are noted with an asterisk), your Part B deductible

Amounts below are based on Medicare’s 2020 cost-share. will have been met for the calendar year.

Services Medicare Pays Plan Pays You Pay

Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies

100% $0 $0

Durable Medical Equipment

First $198 of Medicare-approved amounts* $0 $198

(Part B deductible) $0

Remainder of Medicare-approved amounts 80% 20% $0

Other Benefits – Not Covered by Medicare

Services Medicare Pays Plan 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

20% and amounts over the $50,000 lifetime

maximum

17

* A benefit period begins on the first day you Plan G Medicare (Part A) receive service as an inpatient in a hospital and ends after you have been out of the hospital and

Hospital Services – Per Benefit Period have not received skilled care in any other facility Amounts below are based on Medicare’s 2020 cost-share. for 60 days in a row.

Services Medicare Pays Plan Pays You Pay

Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:

While using 60 lifetime reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare -eligible expenses $0**

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $176 a day Up to $176 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 a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/ coinsurance $0

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

18

* Once you have been billed $198 of Medicare-approved amounts for covered services (which Plan G Medicare (Part B) are noted with an asterisk), your Part B deductible

Medical Services – Per Calendar Year will have been met for the calendar year. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (Above Medicare-approved amounts)

$0 100% $0

Blood

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% 0% 0%

19

* Once you have been billed $198 of Medicare-Plan G Medicare (Parts A&B) approved amounts for covered services (which are noted with an asterisk), your Part B deductible

Amounts below are based on Medicare’s 2020 cost-share. will have been met for the calendar year.

Services Medicare Pays Plan Pays You Pay

Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies

100% $0 $0

Durable Medical Equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Other Benefits – Not Covered by Medicare

Services Medicare Pays Plan 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

20% and amounts over the $50,000 lifetime

maximum

20

* A benefit period begins on the first day you receive service as an inpatient in a hospital and Plan N Medicare (Part A) ends after you have been out of the hospital and

Hospital Services – Per Benefit Period have not received skilled care in any other facility for 60 days in a row. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0

61st thru 90th day All but $352 a day $352 a day $0

91st day and after:

While using 60 lifetime reserve days All but $704 a day $704 a day $0

Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare -eligible expenses $0**

Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0

21st thru 100th day All but $176 a day Up to $176 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 a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare copayment/ coinsurance $0

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

21

* Once you have been billed $198 of Medicare-Plan N Medicare (Part B) approved amounts for covered services (which are noted with an asterisk), your Part B deductible

Medical Services – Per Calendar Year will have been met for the calendar year. Amounts below are based on Medicare’s 2020 cost-share.

Services Medicare Pays Plan Pays You Pay

Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B Excess Charges (Above Medicare-approved amounts)

$0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $198 of Medicare-approved amounts* $0 $0 $198 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Clinical Laboratory Services

Tests for diagnostic services 100% 0% 0%

Note: Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.

22

* Once you have been billed $198 of Medicare-approved amounts for covered services (which Plan N Medicare (Parts A&B) are noted with an asterisk), your Part B deductible

Amounts below are based on Medicare’s 2020 cost-share. will have been met for the calendar year.

Services Medicare Pays Plan Pays You Pay

Home Health Care Medicare-Approved Services Medically necessary skilled care services and medical supplies

100% $0 $0

Durable Medical Equipment

First $198 of Medicare-approved amounts* $0 $0 $198

(Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Services Medicare Pays Plan 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

20% and amounts over the $50,000 lifetime

maximum

23

Nondiscrimination Notice

BlueCross BlueShield of Tennessee (BlueCross), including its subsidiaries SecurityCare of Tennessee, Inc. and Volunteer State Health Plan, Inc. also doing business as BlueCare Tennessee, complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. BlueCross does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

BlueCross:

� Provides free aids and services to people with disabilities to communicate effectively with us, such as: (1) qualified interpreters and (2) written information in other formats, such as large print, audio and accessible electronic formats.

� Provides free language services to people whose primary language is not English, such as: (1) qualified interpreters and (2) written information in other languages.

If you need these services, contact Member Service at the number on the back of your Member ID card or call 1-800-553-8158 (TTY: 711). From Oct. 1 to March 31, you can call us 7 days a week from 8 a.m. to 9 p.m. ET. From April 1 to Sept. 30, you can call us Monday through Friday from 8 a.m. to 9 p.m. ET. Our automated phone system may answer your call outside of these hours and during holidays.

If you believe that BlueCross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance (“Nondiscrimination Grievance”). For help with preparing and submitting your Nondiscrimination Grievance, contact Member Service at the number on the back of your Member ID card or call 1-800-553-8158 (TTY: 711). They can provide you with the appropriate form to use in submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievance to: Nondiscrimination Compliance Coordinator; c/o Manager, Operations, Member Benefits Administration; 1 Cameron Hill Circle, Suite 0019, Chattanooga, TN 37402-0019; (423) 591-9208 (fax); Nondiscrimination_OfficeGM@bcbst.com (email).

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD), 8:30 a.m. to 8 p.m. ET. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

123776_19_NDMLI_C (03/19)

24

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. llame al 1-800-553-8158 (TTY: 711).

Multi Language Services

25

Notes

26

Get in touch with us to learn more.

1-800-247-8510 (TTY: 711)

bcbstmedicare.com

1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbstmedicare.com

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the Blue Cross Blue Shield Association. BlueCross BlueShield of Tennessee complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-553-8158 (TTY: 711).

1-800-553-8158 (TTY:711).ملحوظة: إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية تتوفر لك بالمجان. اتصل برقم