Plan G Certificate - Disability (2024)

Group Medicare Supplement Cer琀椀昀椀cate Plan G by Reason of Disability P.O. Box 327 Seattle, WA 98111-0327 30-DAY RIGHT TO REVIEW PLEASE READ this certificate of coverage ("booklet"). It will explain what is and is not covered. After you have read it, if you are not satisfied, send it back to us within 30 days of the day you received it. We will refund your payment within 30 days of our receipt of the booklet, or we will pay an additional 10 percent penalty which will be added to your refund. Your coverage will then be deemed void from its beginning. SUBSCRIPTION CHARGES The Group may require you to pay the subscription charges for this plan. Payments are due on or before the first of each month. After the due date, we give you ten extra days, beginning with the due date, in which to make your payment. If you do not pay your subscription charges within the ten extra days, your coverage will end without further notice as of the date through which your coverage was paid. Any claims incurred after that date will not be covered. Subscription charges are subject to change. Any change will apply to all subscribers in the same class under this plan. We will notify you 30 days before the change. GUARANTEED RENEWABLE This plan is guaranteed renewable, upon payment of the subscription charges and continuation of the contract by the Group. It can only be canceled if your subscription charges are not paid, if you lose eligibility for coverage under the Group's plan, or if the Group terminates or replaces this plan. If this should happen, you have the right to continued Medicare supplement coverage as stated in Conversion Right in this booklet. Moreover, we can cancel your coverage retroactively for material misrepresentation on your application. (See When Coverage Ends.) If you are aware of any incorrect or incomplete information, you should contact Premera now, before any claim arises. Group Name: Washington State Health Care Authority Contract Effective Date: January 1, 2024 Plan: Group Medicare Supplement Plan G (by reason of disability) Contract Form Number: GMSGD (01-2024) WAMSCOCGrpGDisCert24 050711 (01-01-2024) An Independent Licensee of the Blue Cross Blue Shield Associa琀椀on