MEDICARE PLANS Effective November 1, 2018

MEDICA SIGNATURE SOLUTIONSM

MINNESOTA

Medicare Supplement Plan OptionsCoverage Details

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Medica Signature Solution gives you

the best of all worlds – the freedom

to choose your doctor without any

network restrictions and the security

of knowing you have predictable

coverage that goes with you from

one end of the country to the other.

Talk with an expert consultant you can trust.

Call 1-800-918-2151 (TTY: 711) to speak with a Medicare consultant who can help you evaluate your situation and make the best coverage choice for you and your budget.

Attend a free Medicare Workshop.

To find a workshop near you, visit medica.com/MedicareWorkshops. You’ll learn everything you need to know about Medicare and the affordable plan options from Medica.

Get the details online.

Visit medica.com/Medicare for valuable information and resources to help you make the best coverage decisions.

NATIONWIDECHOICE ANDCOVERAGE.

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Find your best match with Medica. When it’s time to choose your

coverage, Medica has the options

you need to make sure you have

the plan that fits you. We’ve been

serving fellow Minnesotans like

you for over 40 years. Let our

local Medicare consultants help

you find your best match today!.

Looking for a Medicare plan that’s easy to budget for and easy to use no matter where you are?Signature Solution gives you that and more by paying important costs that Medicare does not cover. You decide the level of coverage you want. All options include:

Choice – see any provider that accepts Medicare

Freedom – travel or move anywhere in the U.S.

No surprises – medical coverage you can count on with no unexpected costs

Affordability – competitively-priced premiums for the value you need

COAST-TO-COAST PEACE OF MIND

All the plan features you want and more» Plans with $0 copays for most

medical services*» Coverage options to fit your needs» Free SilverSneakers® fitness

membership with access to 14,000 facilities nationwide

» Personal support services to help you get the care you need

» Discounts on products and services that enhance your life

» Benefits that don’t change from year to year unless you want them to

NEED PART D DRUG COVERAGE? See page 5.

*Deductible applies with some plan options.

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Our Signature Solution plan options provide the following core benefits. The √ means you are covered.

SIGNATURE SOLUTION PUTS YOU IN CONTROL

Signature Solution supplements Original Medicare, which includes Part A and Part B.Part A helps pay for hospital costs for inpatient and skilled nursing care. Most people don’t pay a premium for Part A but there is a deductible.

Part B helps pay for medical costs for doctor visits, tests, outpatient treatment and some medical equipment. You must pay a monthly premium, an annual deductible and coinsurance for Part B.

Signature Solution is a Medicare Supplement plan that helps pay costs not covered by Original Medicare, like Medicare deductibles and coinsurance. How much is covered depends on the options that you select.

Choose from four plan options:» Basic – with this plan you are able to add up to four riders that enhance

your coverage in specific ways or you can choose to select the base plan with no additional riders. If you add riders, the cost for each rider is added to the Basic plan base premium each month.

» Extended Basic – this plan provides very comprehensive coverage. No additional riders are available.

» High Deductible Coverage (Plan HDF) – this plan covers all Medicare-covered benefits at 100% once you have paid the plan annual deductible.

» $20/$50 Copayment (Plan N) – this plan provides essential coverage with affordable cost-sharing once the annual Medicare Part B deductible is met.

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Coverage BasicExtended

Basic

High Deductible Coverage

(Plan HDF)

$20/$50 Copayment

(Plan N)

Part A coinsurance √ √ √ √Part B coinsurance √ √ √ √First three pints of blood each year √ √ √ √

Hospice Part A coinsurance √ √ √ √

100% skilled nursing facility coinsurance* √ √ √ √

100% home health care services and medical supplies

√ √ √ √

Emergency care outside U.S.** √ √ √ √

80% non-emergency care outside U.S. √

*You must meet Medicare’s requirements.** 80% coverage for all plans, except High Deductible Coverage (Plan HDF),

which has 100% coverage once plan deductible is met.

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Access your plan information anytime, anywhere Mymedica.com is a one-stop member resource that puts your health plan benefits and activity at your fingertips. Take advantage of an array of self-service tools that give you access to your Medica plan information 24/7, 365 days a year.

Get help from your local customer service team As a Medica member, you will always receive the caring, personal service you deserve from local Medicare experts. Our health plan specialists can answer your questions and help you maximize your coverage. It’s just one more reason to choose Medica.

Enjoy the perks of being a Medica member

Change your benefits if you need toYou can keep your same

medical benefits from

one year to the next –

guaranteed. But if your

needs change, Signature

Solution is flexible

enough to change with

you. In fact, you can

change your coverage

options at any time of

the year. You are not

limited to an annual

election period.

Medica is pleased to introduce you to SilverScript® Insurance Company Medica customers can enroll in SilverScript (PDP), a Medicare Prescription Drug plan designed to fit your needs and your budget.

SilverScript gives you:

» Affordable coverage options

» A large formulary, including brand name, generic and specialty drugs

» An extensive network of pharmacies nationwide

To learn more or to enroll, call Medica and speak to a licensed agent.

You must continue to pay your Medicare Part B premium.SilverScript is a Prescription Drug Plan with a Medicare contract offered by SilverScript Insurance Company. Enrollment in SilverScript depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The formulary and pharmacy network may change at any time. You will receive notice when necessary.SilverScript Insurance Company is an independent company whose products and services are not Medica products and services. SilverScript Insurance Company is solely responsible for this prescription drug coverage.

Add Part D drug coverage

Y0080_12348_ACQ_2018 CMS Accepted

SELECT THE COVERAGE THAT FITS YOUSIGNATURE SOLUTION PREMIUMS

Basic PlanExtended Basic Plan

High Deductible Coverage(Plan HDF)

$20/$50 Copayment(Plan N)

Base Rate Total with all 4 Riders

Tobacco-Free Standard Tobacco-Free Standard Tobacco-Free Standard Tobacco-Free Standard Tobacco-Free Standard

Monthly Plan Premium $163.60 $190.50 $220.70 $253.80 $228.00 $262.20 $89.30 $102.70 $181.60 $208.80

Part A Hospital Deductible Add Rider 1 : + $38.90 Add Rider 1 : + $44.70 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered ** 100% Covered ** 100% Covered 100% Covered

Part B Medical Deductible Add Rider 2 : + $15.10 Add Rider 2 : + $15.10 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered ** 100% Covered ** Not Covered Not CoveredMedical Expenses that Exceed Medicare Part B Limits Add Rider 3 : + $.90 Add Rider 3 : + $1.00 100% Covered 100% Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Preventive Benefits Not Covered by Medicare - up to $120 per calendar year Add Rider 4 : + $2.20 Add Rider 4 : + $2.50 100% Covered 100% Covered 100% Covered 100% Covered Not Covered Not Covered Not Covered Not Covered

BENEFITS YOU PAY YOU PAY YOU PAY YOU PAY

Plan Deductible $0 $0 $0 $0 $0 $0 $2,240

(for 2018)$2,240

(for 2018)$0 plan deductible once Part B deductible met

$0 plan deductible once Part B deductible met

Maximum Annual Out-of-Pocket CostMinimal to

no cost sharingMinimal to

no cost sharingMinimal to

no cost sharingMinimal to

no cost sharing$1,000 $1,000 No annual limit No annual limit No annual limit No annual limit

Medicare-Covered Preventive Screenings & Services

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Primary Care $0* $0* $0 $0 $0 $0 $0** $0** $20*** $20***

Specialist Visit $0* $0* $0 $0 $0 $0 $0** $0** $20*** $20***

Urgent Care $0* $0* $0 $0 $0 $0 $0** $0** $20*** $20***

Diagnostic Tests $0* $0* $0 $0 $0 $0 $0** $0** $0*** $0***

Lab & Radiology/X-rays $0* $0* $0 $0 $0 $0 $0** $0** $0*** $0***

Diabetes Supplies (Non-Part D) $0* $0* $0 $0 $0 $0 $0** $0** $0*** $0*** Part B Prescription Drugs (Part D drugs not covered)

$0* $0* $0 $0 $0 $0 $0** $0** $0*** $0***

Outpatient Care $0* $0* $0 $0 $0 $0 $0** $0** $0*** $0***

Emergency$0* U.S.

20% Worldwide$0* U.S.

20% Worldwide$0 U.S.

20% Worldwide$0 U.S.

20% Worldwide$0 U.S.

20% Worldwide$0 U.S.

20% Worldwide$0** U.S.

and Worldwide$0** U.S.

and Worldwide$50*** U.S.

20% Worldwide$50*** U.S.

20% WorldwideInpatient Hospital $0† $0† $0 $0 $0 $0 $0** $0** $0 $0

Skilled Nursing Care†† $0 $0 $0 $0 $0 $0 $0** $0** $0 $0

* Part B deductible must be met unless Rider 2 selected. / ** After plan deductible met. / *** After Part B deductible met. / †Part A deductible must be met unless Rider 1 selected. / †† Up to 100 days each benefit period. You must meet Medicare requirements.

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EXTRAS TO HELP KEEP YOU HEALTHY A reliable Medicare plan is only one piece of the puzzle when it comes to maintaining your health. We give you the extra resources you need to stay healthy each and every day.

Stay Active with SilverSneakers®

Signature Solution includes a FREE SilverSneakers membership with Basic, Extended Basic and $20/$50 Copayment (Plan N). This program helps people age 65 and over improve their well being through a variety of fitness options.

» More than 14,000 participating fitness locations nationwide

» Enroll at multiple locations simultaneously

» Access to classes, exercise equipment and other amenities

Visit SilverSneakers.com for a complete list of facilities and options.

Save on Medical Alert SystemsMedica members have access to discounts on retail prices for a variety of medical alert service options from Philips Lifeline, a medical alert provider in the U.S.

Discounts on Hearing AidsMedica members receive pricing that is 30% - 60% off Manufacturer Suggested Retail Price (MSRP) on major hearing aid brands through EPIC Hearing Service Plan.

Save on Lasik Vision Correction As a Medica member, you have access to discounts of up to 50% off Lasik vision correction through the Qualsight Laser Vision Correction Program. The program provides you with a national network of accredited and experienced Lasik surgeons to choose from.

Get the Health Information You NeedAs a Medica member, you will receive our Medica Magazine three times a year. It is full of practical information to help you maintain or improve your well being, including content on topics like preventive care, common health conditions, safety tips, healthy recipes, Medicare updates and more!

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PERSONAL SUPPORT SERVICESSignature Solution includes a number of special services to make your life easier so you have more time to focus on the things you enjoy. These services are provided at no additional cost to you and are strictly confidential.

Consult with a Nurse 24/7 You and your family have a place to turn for trusted advice and information when you need it most.

Through the HealthAdvocateSM NurselineTM, highly-trained nurses are available to help answer your questions about symptoms, medications and health conditions.

These nurses can provide medical evaluation and direction to appropriate care (911, ER or urgent care for life-threatening conditions). And they can offer self-care tips and symptom relief for non-urgent conditions.

Get Personal Advocacy SupportHave questions about your Medica plan coverage? Need help navigating the often complex medical system?

Health Advocate will help you tackle health and insurance-related questions – from finding the right doctor to answering any claims questions. They can even assist you in making an appointment with that hard-to-reach doctor.

Your personal Health Advocate can also help you research resources like adult daycare, assisted living, long-term care and in-home care.

Access Online Wellness InformationLooking for new ways to help improve your health and wellness? HealthAdvocate’s online resource center for Medica members is your one-stop, online support system that puts a large library of health videos and a variety of health assessments at your fingertips.

EligibilityYou are eligible to enroll in Medica Signature Solution if you:

» Are enrolled in Medicare Part A and Part B

» Are a resident of Minnesota at the time of enrollment

HOW TOENROLL INMEDICA SIGNATURESOLUTION

Submit your completed paper forms via mail, fax or web.

Mail to: Medica Medicare Solutions PO Box 6300 Eau Claire, WI 54702-9713

Or fax to: 1-855-250-2166

Or upload securely at: medica.com/EnrollmentUpload

There are three ways to enroll in a Signature Solution plan. Choose the one that works best for you:

Call 1-800-918-2151 (TTY: 711) for fast and easy enrollment over the phone.

Go to medica.com/Medicare to easily complete your enrollment online.

Complete and sign a paper application and submit via mail, fax or web. (You can request a paper application by calling 1-800-918-2151, TTY: 711.)

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Enrollment area Signature Solution is available to residents of all Minnesota counties. (You must be a Minnesota resident at the time of enrollment.)

When to EnrollThe best time to enroll in a

Medicare Supplement plan (also

known as a Medigap plan) is

during the six-month Medigap

Open Enrollment Period which

begins the month you’re first

enrolled in Medicare Part B.

During this time you can buy

any Medicare Supplement

(Medigap) policy sold in your state,

regardless of your health.

You can apply for coverage at any

time after your Medigap Open

Enrollment Period too though you

could be required to provide your

health history and be medically

underwritten.

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The SilverSneakers® fitness program is provided by Tivity Health, an independent company. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries. HealthAdvocateSM is a service mark of Health Advocate, Inc. © 2018 Medica. Medica® is a registered service mark of Medica Health Plans. Medica Signature SolutionSM is a service mark of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured, Medica Health Management, LLC and MMSI, Inc.

Social Security Administration

Toll free at 1-800-772-1213(TTY 1-800-325-0778)

Hours of operation: 7 a.m. to 7 p.m., Monday-Fridayssa.gov

Follow Medica:Centers for Medicare & Medicaid Services (CMS)

Toll free at 1-800-MEDICARE (1-800-633-4227)(TTY 1-877-486-2048)

Hours of operation: 24 hours a day, seven days a weekmedicare.gov

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MEDICA.THE FIRST WORD IN MEDICARE.

Call toll free at 1-800-918-2151 (TTY: 711) Hours of operation: October 1–March 318 a.m. to 8 p.m. Central, seven days a week

April 1–September 30 8 a.m. to 8 p.m. Central, Monday-Friday

Visit us online at medica.com/Medicare.

Locate a Medicare Workshop near you at medica.com/MedicareWorkshops.

Find a broker in your community at medica.com/Medicare.