applying for coverage through the PEBB Program. Premera Blue Cross determines eligibility for an applicant applying for coverage as a state resident. The benefits available under this Medicare Supplement plan described in this certificate of coverage are the same whether you enroll through the PEBB Program or enroll as a state resident, however, other provisions in this certificate may not apply or may be different for those that enroll through the PEBB Program as PEBB Program rules will apply. LATE AND OPEN ENROLLMENT If an eligible person fails to enroll for coverage under this plan when first eligible, the person may enroll only as described below. Open Enrollment The Group has the option of setting an open enrollment period for eligible people who did not enroll when first eligible. Not all groups allow open enrollment periods. Open enrollment rights may also differ between classes of eligible people. Dependents must enroll on the same plan as the subscriber unless otherwise required by law or allowed by the Group's eligibility and enrollment rules. Late Enrollment When Allowed By Law People who are otherwise eligible for this plan may also apply when they lose coverage as described below. When they apply, they must give us proof that they had and lost the coverage as described below. Eligible people may apply if: • They lost retiree coverage through a group health plan sponsored by one or more employers or employee organizations. • They left this plan to try a Medicare Advantage plan, Program of All-Inclusive Care for the Elderly (PACE), or Medicare cost, risk, or Select plan for the first time. They may apply if they tried one plan, more than one plan of the same type, or more than one type of plan. However, all four statements below must be true: • They were covered under each plan for less than 12 months. • Each plan (other than the most recent) must have been terminated involuntarily. • They switched plans within 63 days of the date the prior plan terminated, with no other coverage in between. • The effective date of the last plan was less than 2 years after the effective date of the first plan. • At age 65 and upon first becoming eligible for Medicare Part A, they enrolled in one or more Medicare Advantage or PACE plans. All four statements above must also be true. 5 Group Plan G/Age