Outline of Coverage - Premera Blue Cross

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FPLAN F (continued):OTHER BENEFITS - NOT COVERED BY MEDICAREMEDICARESERVICESPLAN F PAYS YOU PAYPAYSFOREIGN TRAVEL - Not covered by MedicareMedically necessary emergency care services beginning during the first 60 days of each trip outsidethe USAFirst $250 each calendar year $0 $0 $250Remainder of charges $080% to a lifetimemaximum benefitof $50,00020% and amountsover the $50,000lifetime maximum8
FHIGH DEDUCTIBLE PLAN F:MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out ofthe hospital and have not received skilled care in any other facility for 60 days in a row.**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefitsfrom the High Deductible Plan F will not begin until out of pocket expenses are $2,180. Out-of-pocket expenses for thisdeductible are expenses that would ordinarily be paid by the plan. This includes the Medicare deductibles for Part A and PartB, but does not include the plan’s separate foreign travel emergency deductible.SERVICESMEDICAREPAYSAFTER YOU PAY$2,180DEDUCTIBLE**,PLAN F PAYSIN ADDITION TO$2,180DEDUCTIBLE**,YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and suppliesFirst 60 days All but $1,260$1,260(Part A Deductible)$061st through 90th day All but $315 a day $315 a day $091st day and after:(while using 60 lifetime reserve days)All but $630 a day $630 a day $0Once lifetime reserve days are used:• Additional 365 days$0100% of Medicareeligible expenses$0***• Beyond the additional 365 days $0 $0 All costsSKILLED NURSING FACILITY CARE*You must meet Medicare's requirements, including having been in a hospital for at least 3 days andentered a Medicare-approved facility within 30 days after leaving the hospitalFirst 20 daysAll approvedamounts$0 $021st through 100th dayAll but $157.50a dayUp to $157.50a day101st day and after $0 $0 All costsBLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0HOSPICE CAREYou must meet Medicare'srequirements, including a doctor'scertification of terminal illness.All but very limitedcopayment /coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment /coinsurance***NOTICE: When your Medicare Part A hospital benefits are exhausted, the carrier stands in the place of Medicare and willpay whatever amount Medicare would have paid for up to an additional 365 days as provided in the plan’s Basic Benefits.During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed chargesand the amount Medicare would have paid.$0$09
Page 1 and 2: Outline of Medicare Supplement Cove
Page 6 and 7: FPLAN F:MEDICARE (PART A) - HOSPITA
Page 10 and 11: FHIGH DEDUCTIBLE PLAN F (continued)
Page 12 and 13: NPLAN N:MEDICARE (PART A) - HOSPITA
Page 14: NPLAN N (continued):MEDICARE (PARTS

Outline of Coverage - Premera Blue Cross

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