Outline of Supplemental Coverage (2024)

Outline of Medicare Supplement Coverage Washington State Health Care Authority See Outlines of Coverage sections for details about all plans. This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Only applicants before 2020 may purchase Plans C, F, and high deductible F. Note: A  means 100% of the benefit is paid. Medicare Plans Available to All Applicants first eligible Benefits before 2020 only 1 2 2 3 1 A B D G K L M N C F 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   apply Blood (first three pints)     50% 75%     Part A hospice care coinsurance     50% 75%     or copayment Skilled nursing facility   50% 7     coinsurance 5% 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 $7,060 $3,530 1 Plan F and G also have a high deductible option which require first paying a plan deductible of $2,800 before the plan begins to pay. Once the plan deductible is met, the plan pays 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 F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible. 2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 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 do not result in an inpatient admission. 021605 (08-10-2021) 021777 (10-15-2023) An Independent Licensee of the Blue Cross Blue Shield Association

Washington State Health Care Authority SUBSCRIPTION CHARGES AND PAYMENT INFORMATION (Rates effective January 1, 2024) Eligible By Reason Of Age Subscription Charges - Per Month PEBB Retiree PEBB Retiree & Spouse State Resident State Resident & Spouse Plan G $101.99 Plan G $198.02 Plan G $192.06 Plan G $384.12 Eligible By Reason Of Disability Subscription Charges - Per Month PEBB Retiree PEBB Retiree & Spouse State Resident State Resident & Spouse Plan G $169.20 Plan G $332.44 Plan G $326.49 Plan G $652.98 Please Note: The subscription charge amount charged is the same for all plan subscribers with certificates like yours. However, the actual amount a plan subscriber pays can vary depending on if and how much the group contributes toward a particular class of subscribers’ subscription charges. SUBSCRIPTION CHARGE INFORMATION We (Premera) can only raise your subscription charges if we raise the subscription charges for all certificates like yours in this state. DISCLOSURES Use this outline to compare benefits and subscription charges among plans. READ YOUR CERTIFICATE VERY CAREFULLY This is only an outline describing your certificate's most important features. The Group policy is the insurance contract. You must read the certificate itself to understand all of the rights and duties of both you and your Medicare supplement carrier. RIGHT TO RETURN CERTIFICATE If you find that you are not satisfied with your certificate, you may return it to PO Box 327, MS 295, Seattle, Washington 98111. If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and all of your payments will be returned. CERTIFICATE REPLACEMENT If you are replacing another health insurance certificate, do NOT cancel it until you have actually received your new certificate and are sure you want to keep it. NOTICE This certificate may not fully cover all of your medical costs. Neither Premera nor its producers 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 Be sure to answer truthfully and completely all questions. Review the application carefully before you sign it. Be certain that all information has been properly recorded.

PLAN G: MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD G *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. SERVICES MEDICARE PLAN G PAYS YOU PAY PAYS HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,632 $1,632 $0 (Part A Deductible) 61st through 90th day All but $408 a day $408 a day $0 91st day and after: All but $816 a day $816 a day $0 (while using 60 lifetime reserve days) Once lifetime reserve days are used: $0 100% of Medicare $0*** • Additional 365 days eligible expenses • 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 $0 $0 amounts 21st through 100th day All but $204 Up to $204 $0 a day 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 All but very limited requirements, including a doctor's copayment / Medicare certification of terminal illness. coinsurance for copayment / $0 outpatient drugs coinsurance and inpatient respite care ***NOTICE: When your Medicare Part A hospital benefits are exhausted, the carrier 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 plan’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. GOCW-G

PLAN G (continued): G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR * Once you have been billed $240 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PLAN G PAYS YOU PAY PAYS 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 $240 of Medicare approved $240 amounts* $0 $0 (Part B Deductible) Remainder of Medicare approved Generally 80% Generally 20% $0 amounts Part B Excess Charges $0 100% $0 (above Medicare approved amounts) BLOOD First 3 pints $0 3 pints $0 Next $240 of Medicare approved $240 amounts* $0 $0 (Part B Deductible) Remainder of Medicare approved 80% 20% $0 amounts CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% $0 $0 MEDICARE (PARTS A & B) HOME HEALTH CARE - Medicare approved services Medically Necessary Skilled Care 100% $0 $0 Services and Medical Supplies Durable Medical Equipment First $240 of Medicare approved $0 $0 $240 amounts* (Part B Deductible) Remainder of Medicare approved 80% 20% $0 amounts OTHER BENEFITS - NOT COVERED BY MEDICARE 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 80% to a lifetime 20% and amounts Remainder of charges $0 maximum benefit over the $50,000 of $50,000 lifetime maximum GOCW-G

Discrimination is Against the Law Premera Blue Cross (Premera) complies with applicable Federal and Washington state civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592, TTY: 711, Email [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 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 Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can also file a civil rights complaint with the Washington State Office of the Insurance Commissioner, electronically through the Office of the Insurance Commissioner Complaint Portal available at https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status, or by phone at 800-562-6900, 360-586-0241 (TDD). Complaint forms are available at https://fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx. Language Assistance ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-722-1471 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-722-1471（TTY：711）。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 800-722-1471 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-722-1471 (TTY: 711) 번으로 전화해 주십시오. 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Bilbilaa 800-722-1471 (TTY: 711). .)711 :م كبلاو مصلا فتاه م قر( 800-722-1471 م قرب لصتا .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تام دخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 800-722-1471 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-722-1471 (TTY: 711). ້ ່ ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫຼື ອດ້ານພາສາ, ໂດຍບໍ ເສັ ຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ. ໂທຣ 800-722-1471 (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-722-1471 (TTY: 711). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-722-1471 (ATS : 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-722-1471 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-722-1471 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-722-1471 (TTY: 711). . د ی ر ی گب سامت 800-722-1471 (TTY: 711) اب .د شاب ی م م هارف امش ی ارب ناگی ار تروصب ی نابز تلای هست ،دینک ی م وگتفگ یسراف نابز هب رگا :هجوت 037397 (07-01-2021) An independent licensee of the Blue Cross Blue Shield Association