Choosing your Blue 65 Plan

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Choosing your

Blue 65 Plan

^SM

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is Your Best Buy

Blue 65

If you have Medicare coverage, you know that many medical costs are left for you to pay. Blue Cross & Blue Shield of Mississippi offers you a choice of six Medicare Supple- ment plans so you can select the one that offers the benefits you want with a monthly premium that fits your budget.

You should read the Medicare publications

“Medicare & You” and “Choosing a Medigap Policy” for explanations of Medicare benefits and Medicare Supplement insurance.

Free copies are available by calling 1-800-MEDICARE (1-800-633-4227), or by visiting the www.medicare.gov website.

Our Blue 65 Medicare Supplement policies reflect our commitment since 1947 of providing quality healthcare coverage at the lowest possible cost. Medicare Supplement policies are standardized, but the companies offering them vary considerably. With Blue Cross & Blue Shield of Mississippi, your Medicare Supplement coverage is backed by financial stability, efficient, caring customer service and more.

Why ^Notes

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1

Eating healthy, exercising, being tobacco-free and visiting a physician regularly can make a difference in both your health and your healthcare costs. As Mississippi’s health and wellness leader, we’re committed to providing you with the information and resources to help you be healthy. We update our website at www.bcbsms.com regularly with timely health and wellness information.

Use Medicare

Preventive Services

The federal Medicare Program provides certain preventive services to help you and your healthcare provider assess your current health status and spend time discussing ways to maintain or improve your health. Learn more about these benefits at www.medicare.gov. Be sure your physician is a part of the Blue Cross & Blue Shield of Mississippi Provider Network and that your healthcare provider accepts Medicare.

Stay Active

Routine physical activity is effective in slowing down or preventing some normal changes that occur with age. The U.S. Surgeon General recommends that Americans achieve 30 minutes of aerobic activity on most days. Whether this is through walking or other exercise, it’s important to be active.

Select wellness centers throughout the state offer discounts to people who show their Blue Cross & Blue Shield of Mississippi ID cards when they join. This can give you the advantage of personal fitness consultations along with cost savings and a range of exercise classes and equipment. Find details on the

Wellness Center Discount Program online at www.bcbsms.com. Consult with a physician before starting a new physical activity program.

Eat Healthy

A healthy diet includes plenty of fruits, vegetables, whole grains, and low-fat or fat-free dairy

products. Protein choices should include fish, beans and peas. It’s wise to select food that’s low in saturated fat, trans fat and sodium. Choose balanced meals with the right portion sizes to help prevent, or even reverse, chronic health conditions such as high blood pressure, high cholesterol and/or diabetes.

Stay Socially Involved

A part of staying healthy is to stay involved with people and remain socially active. Keeping

friendships, making plans and going places is fun and a healthful activity. It’s good to participate in activities that enrich your life as well as others. This could be volunteer work, a new hobby, getting a pet and inviting people to visit you.

Important Health and Wellness Information

Notes

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27 Outline of Medicare Supplement Coverage

This chart shows the benefits included in each of the standard Medicare Supplement plans. This provides a quick look at the benefits that are a part of each of the standardized Medicare Supplement Plans available for purchase. More detailed information about these Plans’ benefits is found on pages 12-17 of this brochure. Once you have decided which benefits you would like to have, you can read the instructions on page 4 and complete the application that begins on page 5.

Basic Benefits include the following:

Hospitalization: Part A coinsurance plan coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services.

Blood: First three pints of blood each year. Hospice: Part A coinsurance.

Notice:

While Blue 65 pays for most expenses not paid by Medicare, it may not fully cover all of your medical costs. As a buyer of Medicare Supplement coverage, you are advised to review all policy limitations carefully. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or read “Medicare and You,” a government booklet available at the www.medicare.gov website. Farm Bureau and Blue Cross & Blue Shield of Mississippi are not connected with Medicare, and the Blue 65 Medicare Supplement policy is not connected with or endorsed by the U.S. Government or the Federal Medicare Program.

Disclosures

Use this outline and premium information to compare benefits and premiums among policies. This outline shows benefits of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits.

A B C D F G

Basic, including 100% Part B

coinsurance

coinsurance Skilled

Nursing Facility Coinsurance

Skilled Nursing Facility

Coinsurance

Coinsurance Part A

Deductible

Part A Deductible

Part A Deductible Part B

Deductible

Part B Deductible Part B Excess

(100%)

Part B Excess (100%) Foreign

Travel Emergency

Foreign Travel Emergency

Plan G

Medicare Parts A & B

Plan G

Other Benefits - Not Covered by Medicare

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

APPROVED SERVICES - Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment

First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B

deductible)

Remainder of Medicare Approved Amounts 80% 20% $0

Services Medicare Pays Plan Pays You Pay

FOREIGN TRAVEL –

NOT COVERED BY

MEDICARE - Medically necessary skilled care services and medical supplies beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

Remainder of charges $0

80% to a lifetime maximum benefit

of $50,000

20% and amounts over the $50,000 lifetime maximum

live healthy.

* Once you have been billed $162 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.

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3 Plan G

Medicare (Part B) - Medical Services - Per Calendar Year

Services Medicare Pays Plan Pays You Pay

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

deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

^$0 ^100% ^$0

BLOOD

First 3 Pints $0 All costs $0

Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B

deductible)

CLINICAL LABORATORY SERVICES*

TESTS FOR DIAGNOSTIC SERVICES ^100% ^$0 ^$0

be healthy.

Premium Information

We can raise your premium only if we raise the premium for all policies like yours in this state. Premiums are based on the age, gender and location of the insured and will increase each year at the renewal date. You can get premium information online at www.bcbsms.com or through your Certified Blue Cross & Blue Shield of Mississippi Agent.

Policy Replacement

If you are purchasing Blue 65 as a replacement for another health insurance policy, do NOT cancel your other policy until you have received your new Blue 65 policy, reviewed it carefully and are sure you want to keep it.

Money-back Guarantee

If your application is approved, we will send your Blue 65 ID card and policy. Read the policy carefully, including its limitations and exclusions, to understand all of the rights and duties of both you and Blue Cross & Blue Shield of Mississippi. If you are not completely satisfied, return them to us within 30 days after you receive them. We will gladly refund any payments you have made (less any benefits provided).

High Deductible

F ^K ^L ^M ^N

Basic, including 100% Part B coinsurance

Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance,

except up to $20 copayment for office

visit, and up to

$50 copayment for ER Skilled Nursing

Facility Coinsurance

50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance Part A

Deductible

50% Part A Deductible

Part A Deductible Part B

Deductible

Foreign Travel Emergency

Foreign Travel Emergency Part B Excess

(100%)

Out-of-pocket limit

$4,640; paid at 100% after limit reached

Out-of-pocket limit

$2,320; paid at 100% after limit reached

Blue Cross & Blue Shield of Mississippi offers Plans A, B, C, D, F and G. We do not offer Plans F (High Deductible), K, L, M and N, but we are required to inform you of these products. Plans E, H, I and J are no longer available for sale.

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25 Medicare Supplement Application

Please read the following information carefully and select the option which applies

to you.

I

f you enrolled in Medicare Part B within the past six months, you can enroll without underwriting.

• Complete pages 5, 6 and 8.

• Complete page 9 if you are selecting automatic bank draft billing.

• If you are applying for this Medicare Supplement through a Certified Blue Cross & Blue Shield of Mississippi Agent, have your agent complete pages 10 and 11.

Page 10 should be sent with your application. Keep page 11 for your records.

If you have been enrolled in Medicare Part B for more than six months, you are outside the

enrollment period and your Application is subject to underwriting unless the next section applies to you.

• Complete pages 5, 6, 7 and 8.

Page 10 should be sent with your application. Keep page 11 for your records.

If you are enrolled in Medicare Part B and have lost certain types of healthcare coverage, you may have a 63-day open enrollment period without underwriting.

• Complete pages 5, 6 and 8.

Page 10 should be sent with your application. Keep page 11 for your records. Please return all completed forms to:

Blue Cross & Blue Shield of Mississippi

P.O. Box 2312

Jackson, Mississippi 39215-2312

PLEASE DOUBLE CHECK

to make sure you have answered all the questions and signed all applicable sections of the application. Otherwise, the application may have to be returned to you, which may delay the processing.

Complete answers are very important.

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

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

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

Semi-private room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,132 $1,132 (Part A

deductible) ^$0

61st thru 90th day All but $283 a day $283 a day $0

91st day and after:

While using 60 lifetime reserve days All but $566 a day $566 a day $0 Once lifetime reserve days are used

Additional 365 days $0 100% of Medicare

eligible expenses ^$0**

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

amounts ^$0 ^$0

21st thru 100th day All but $141.50

a day Up to $141.50

a day ^$0

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

requirements, including a doctor’s certification of terminal illness.

All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer 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 policy’s “Core 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.

* 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.

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5 Medicare Supplement Application

Last Name/First Name/Initial Sex Date of Birth

M F ^Month ^Day ^Year

Street Address City _MS Zip County

Social Security Number Telephone Number ^Email

Are you now or have you ever been covered by any Blue Cross and/or Blue Shield Plan? ❏ YES ❏ NO If yes, contract holder’s name Last date of coverage

Identification number Headquarter city/state

Please print in ink. Applicants must be 65 years of age or older, enrolled in Parts A and B of Medicare and residents of Mississippi. Disabled persons who are under age 65, and were eligible for Part B of Medicare

in the last six months, and residents of Mississippi may also apply. A separate application is required for each individual. Do not include a payment or check with this application.

I am applying for Plan:

❏ _A ❏ _B ❏ _C ❏ _D ❏ _F ❏ _G

For Office use only-do not complete

Group number: Type contract:

Contract date: Waiver code: Agent code:

Are you now or have you ever been covered by a Medicare Supplement Plan? ❏ YES ❏ NO

If yes, what company Last date of coverage

Reason for termination

If you are applying through a Farm Bureau agent, please provide your

Farm Bureau number: ________________________

If you are applying through a Certified Agent, please provide

Agent/Broker number:________________________

How often do you wish to pay?

❏_Monthly ❏_Quarterly ❏ Semi-annually ❏ Annually

NOTE: For your convenience, we recommend you have your payments paid directly through a bank draft on your checking account. Bank draft is available on a monthly basis only. Please complete the enclosed Individual Bank Draft Authorization Agreement for this service and send it in with this application.

Please copy this information directly from your Medicare Card, or your application will be returned. Part A (Hospital) Effective date Part B (Medical) Effective date Medicare card number

(ex. 000-00-000-A)

❏ _{YES ❏ NO}

Month Day Year

❏ _{YES ❏ NO}

Month Day Year

Plan F

Medicare Parts A & B

Plan F

Other Benefits - Not Covered by Medicare

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

First $162 of Medicare Approved Amounts* $0 $162 (Part B

deductible) ^$0

Services Medicare Pays Plan Pays You Pay

FOREIGN TRAVEL –

NOT COVERED BY

of $50,000

be healthy.

live healthy.

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23

1. a) Did you turn 65 in the last 6 months? qYes qNo, under 65

qNo, 65 more than 6 months

b) Did you enroll in Medicare Part B in the last 6 months?

qYes qNo

c) If yes, what was the effective date?

______________________________________ 2. a) Are you covered for medical assistance through

the state Medicaid program? [NOTE TO

APPLICANT: If you are participating in a “Spend- Down Program” and have not met your “Share of Cost,” please answer NO to this question.] qYes qNo

If yes,

b) Will Medicaid pay your premiums for this Medicare Supplement policy?

qYes qNo

c) Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

qYes qNo

3. a) If you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan, leave “END” blank.

Start___/___/___ End___/___/___

b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy?

qYes qNo

c) Is this your first time in this type of Medicare plan?

qYes qNo

d) Did you drop a Medicare Supplement policy to enroll in the Medicare plan?

qYes qNo

4. a) Do you have another Medicare Supplement policy in force?

qYes qNo

b) If so, with what company, and what plan do you have?

_____________________________________ _____________________________________ c) If so, do you intend to replace your current Medicare Supplement policy with this policy? qYes qNo

(If you answer “Yes” to 4c, your signature is needed on page 10.)

5. a) Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan.) You must include a copy of your certificate of creditable coverage or loss of coverage notice from your prior carrier with this application.

qYes qNo

b) If so, with what company and what kind of policy?

________________________________________ ________________________________________ ________________________________________ ________________________________________ c) What are your start dates of coverage under the other policy? Start___/___/___ End___/___/___ (If you are still covered under the other policy, leave “END” blank.)

6. Have you smoked tobacco products within the past 12 months?

qYes qNo

7. Have you used smokeless tobacco products within the past 12 months?

qYes qNo

8. Has any other individual living in your household, including those not applying for coverage, smoked tobacco products within the past 12 months? qYes qNo

Please remember to sign page 8 before returning the application.

Please answer all questions: Medicare (Part B) - Medical Services - Per Calendar Year ^{Plan F}

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

deductible) ^$0

Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

^$0 ^100% ^$0

BLOOD

Next $162 of Medicare Approved Amounts* $0 $162 (Part B

deductible) ^$0

CLINICAL LABORATORY SERVICES*

be healthy.

live healthy.

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7

1. Have you been advised by a physician to receive inpatient hospital treatment or undergo a surgical operation which has not been performed? qYes qNo

2. Are you currently a patient in either a hospital, nursing home, or medical care facility? qYes qNo

3. Have you been hospitalized during the past 5 years with a diagnosis of, or treatment for, heart condition or circulatory system, such as hardening of the arteries? (Does not include high blood pressure.) q Yes q No

4. Have you been treated in the past 5 years for Alzheimer’s disease, diabetes requiring insulin, emphysema or other obstructive lung disease, internal cancer, kidney disease requiring dialysis, Parkinson’s disease, or stroke?

qYes qNo

5. Have you been treated in the past 5 years for hypertension, TB, AIDS, HIV, tumor, ulcer, eye, ear, nose or throat disorder, liver disease,

hepatitis, arthritis, alcoholism, drug abuse, mental or nervous disorder?

(If yes, indicate which disease/disorder.)

qYes ____________________________________ qNo

6. Do you take prescription drugs on a regular (daily or weekly) basis? If yes, please list drug name(s) and reason why taken. q Yes q No

Drug ________________________________ Reason __________________________________________ Drug ________________________________ Reason __________________________________________ Drug ________________________________ Reason __________________________________________ Drug ________________________________ Reason __________________________________________

Height: Feet Inches Weight:

Question

Number Nature of Ailment Duration Dates

From To Degree of Recovery Name of Physician Hospital or Clinic Give complete details regarding any of the questions above to which you answered “Yes.”

Applicants must complete this page if enrolled under Medicare Part B for more than six months. Blue Cross

& Blue Shield of Mississippi will use the information provided in this application to make its determination about your eligibility. If information about your medical background is misstated or omitted, it could result in rescission of the policy. If your policy is rescinded, it will be deemed never to have been in effect, and you will receive a refund of premiums paid, minus benefits paid. You must disclose ANY AND ALL MEDICAL INFORMATION regarding any of the questions listed below. If you are not sure whether the information is relevant, include it so that Blue Cross & Blue Shield of Mississippi can make that determination. You must check “Yes” if you have been AWARE OF, EVALUATED, DIAGNOSED, TREATED FOR OR RECEIVED ADVICE related to the questions below from any type of healthcare professional during the five-year period prior to this application. However, in answering the questions below please do not provide any genetic information. That is, please do not provide any family medical history or any information related to genetic testing, genetic services, genetic counseling, or genetic education. NOTE: YOU ARE REQUIRED TO REPORT ANY CHANGE IN YOUR HEALTH STATUS DURING THE PERIOD OF PROCESSING. AN UNREPORTED CHANGE WILL BE TREATED AS A NONDISCLOSURE AND COULD RESULT IN RESCISSION OF COVERAGE.

Evidence of Insurability

Plan F

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

deductible) ^$0

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day Up to $141.50

a day ^$0

BLOOD

HOSPICE CARE

$0

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21 All Applicants must read and sign below.

1. You do not need more than one Medicare Supplement policy. 2. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

3. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy.

4. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstated, if requested, within 90 days of losing Medicaid eligibility. If the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstated policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of the suspension. 5. If you are eligible for and have enrolled in a Medicare

Supplement policy by reason of disability and you later become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare Supplement policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you suspend your Medicare Supplement policy under these circumstances, and later lose your employer or union-based group health plan, your suspended Medicare Supplement policy (or, if that is no longer available, a substantially equivalent policy) will be reinstated if requested within 90 days of losing your employer or union-based health plan. If the Medicare Supplement

policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstated policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the suspension.

6. Counseling services may be available to provide advice concerning your purchase of Medicare Supplement insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

7. If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the notice from your prior insurer with your application. 8. With the submission of my signed application, I hereby

authorize any doctor to furnish you any and all medical information pertaining to any condition or treatment. Additionally, I attest that the information is true and complete.

Applicant Signature: _______________________ Date: ___________________________________

Acknowledgement and Authorization

Plan D

Medicare Parts A & B

Plan D

Other Benefits - Not Covered by Medicare

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

deductible)

Services Medicare Pays Plan Pays You Pay

FOREIGN TRAVEL –

NOT COVERED BY

of $50,000

live healthy.

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9 Plan D

Medicare (Part B) - Medical Services - Per Calendar Year

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

deductible)

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

^$0 ^$0 ^{All costs}

BLOOD

deductible)

CLINICAL LABORATORY SERVICES*

be healthy.

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19

RETURN THIS COMPLETED PAGE WITH YOUR APPLICATION.

According to your application, you intend to terminate existing Medicare Supplement or Medicare Advantage insurance and replace it with a policy to be issued by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.

You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare Supplement coverage is a wise decision, you should terminate your present Medicare Supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.

STATEMENT TO APPLICANT BY INSURER, AGENT OR BROKER:

I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare Supplement policy will not duplicate your existing Medicare Supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one): __ Additional benefits.

__ No change in benefits, but lower premiums. __ Fewer benefits and lower premiums.

__ My plan has outpatient prescription drug coverage and I am enrolling in Part D.

__ Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment

___________________________________________ ___________________________________________ Other (please specify):

___________________________________________ ___________________________________________ 1. Note: If the issuer of the Medicare Supplement policy being applied for does not, or is otherwise prohibited from imposing pre-existing condition limitations, please skip to statement 2 below. Health conditions which you may presently have (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

2. State law provides that your replacement policy or certificate may not contain new pre-existing conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. Pre-existing condition means any injury, illness or congenital defect, or condition related to injury, illness or congenital defect for which you received medical care, treatment, consultation, or prescribed drugs during the 6-month period immediately preceding your effective date of coverage.

3. If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.

AGENT/BROKER SIGNATURE

Please print name X ___________________________ Signature X __________________________________ DATE _______________

AGENT/BROKER CODE (REQUIRED):

_______________________________________

APPLICANT SIGNATURE

(Applicant sign if replacing existing coverage.)

X __________________________________________ DATE_______________________________________

Notice to Applicant Regarding Replacement of

Medicare Supplement Coverage or Medicare Advantage

Blue Cross & Blue Shield of Mississippi, P.O. Box 2312, Jackson, MS 39215-2312

Plan D

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

deductible) ^$0

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day Up to $141.50

a day ^$0

BLOOD

HOSPICE CARE

$0

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11

SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE.

According to your application, you intend to terminate existing Medicare Supplement or Medicare Advantage insurance and replace it with a policy to be issued by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company. Your new policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.

You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare Supplement coverage is a wise decision, you should terminate your present Medicare Supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. STATEMENT TO APPLICANT BY INSURER, AGENT OR BROKER:

I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare Supplement policy will not duplicate your existing Medicare Supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare Supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason (check one):

__ Additional benefits.

__ No change in benefits, but lower premiums. __ Fewer benefits and lower premiums.

__ My plan has outpatient prescription drug coverage and I am enrolling in Part D.

__ Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment

___________________________________________ ___________________________________________ Other (please specify):

___________________________________________ ___________________________________________ 1. Note: If the issuer of the Medicare Supplement policy being applied for does not, or is otherwise prohibited from imposing pre-existing condition limitations, please skip to statement 2 below. Health conditions which you may presently have (pre- existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new

policy, whereas a similar claim might have been payable under your present policy.

2. State law provides that your replacement policy or certificate may not contain new pre-existing conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy. Pre-existing condition means any injury, illness or congenital defect, or condition related to injury, illness or congenital defect for which you received medical care, treatment, consultation, or prescribed drugs during the 6-month period immediately preceding your effective date of coverage.

3. If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.

AGENT/BROKER SIGNATURE

Please print name X ___________________________ Signature X __________________________________ DATE _______________

AGENT/BROKER CODE (REQUIRED):

_______________________________________

APPLICANT SIGNATURE

(Applicant sign if replacing existing coverage.)

X __________________________________________ DATE_______________________________________

Notice to Applicant Regarding Replacement of

Medicare Supplement Coverage or Medicare Advantage

Blue Cross & Blue Shield of Mississippi, P.O. Box 2312, Jackson, MS 39215-2312

Plan C

Medicare Parts A & B

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

deductible) ^$0

Plan C

Other Benefits - Not Covered by Medicare

Services Medicare Pays Plan Pays You Pay

FOREIGN TRAVEL –

NOT COVERED BY

of $50,000

be healthy.

live healthy.

(14)

17 Plan A

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

First 60 days All but $1,132 $0 $1,132 (Part A

deductible)

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day ^$0 Up to $141.50

a day

BLOOD

HOSPICE CARE

All but very limited copayment/ coinsurance for outpatient drugs

and inpatient respite care

$0

Plan C

Medicare (Part B) - Medical Services - Per Calendar Year

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

deductible) ^$0

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

BLOOD

Next $162 of Medicare Approved Amounts* $0 $162 (Part B

deductible) ^$0

CLINICAL LABORATORY SERVICES*

be healthy.

live healthy.

(15)

13 Plan A

Medicare (Part B) - Medical Services - Per Calendar Year

Plan A

Medicare Parts A & B

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

BLOOD

deductible)

CLINICAL LABORATORY SERVICES*

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

deductible)

Plan C

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

deductible) ^$0

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day Up to $141.50

a day ^$0

BLOOD

HOSPICE CARE

$0

(16)

15 Plan B

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

deductible) ^$0

Additional 365 days $0 100% Medicare

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day ^$0 Up to $141.50

a day

BLOOD

HOSPICE CARE

$0

Plan B

Medicare (Part B) - Medical Services - Per Calendar Year

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

BLOOD

deductible)

CLINICAL LABORATORY SERVICES*

Plan B

Medicare Parts A & B

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

deductible)

(17)

15 Plan B

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

deductible) ^$0

Additional 365 days $0 100% Medicare

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day ^$0 Up to $141.50

a day

BLOOD

HOSPICE CARE

$0

Plan B

Medicare (Part B) - Medical Services - Per Calendar Year

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

BLOOD

deductible)

CLINICAL LABORATORY SERVICES*

Plan B

Medicare Parts A & B

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

deductible)

(18)

13 Plan A

Medicare (Part B) - Medical Services - Per Calendar Year

Plan A

Medicare Parts A & B

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

IN OR OUT OF

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

BLOOD

deductible)

CLINICAL LABORATORY SERVICES*

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

MEDICARE

100% $0 $0

deductible)

Plan C

Medicare (Part A) - Hospital Services - Per Benefit Period

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

*

deductible) ^$0

SKILLED NURSING FACILITY CARE*

amounts ^$0 ^$0

a day Up to $141.50

a day ^$0

BLOOD

HOSPICE CARE

$0

Choosing your Blue 65 Plan

Choosing your

Blue 65 Plan

is Your Best Buy

Blue 65

Why Notes

1

Use Medicare

Preventive Services

Stay Active

Eat Healthy

Stay Socially Involved

Important Health and Wellness Information

Notes

27

Outline of Medicare Supplement Coverage

Basic Benefits include the following:

Notice:

Disclosures

A B C D F G

Plan G

Medicare Parts A & B

Plan G

Other Benefits - Not Covered by Medicare

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

Services Medicare Pays Plan Pays You Pay

FOREIGN TRAVEL –

live healthy.

3

Plan G

Medicare (Part B) - Medical Services - Per Calendar Year

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

BLOOD

CLINICAL LABORATORY SERVICES*

be healthy.

Premium Information

Policy Replacement

Money-back Guarantee

F K L M N

25

Medicare Supplement Application

Please read the following information carefully and select the option which applies

to you.

I

Blue Cross & Blue Shield of Mississippi

P.O. Box 2312

Jackson, Mississippi 39215-2312

PLEASE DOUBLE CHECK

Complete answers are very important.

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

Services Medicare Pays Plan Pays You Pay

HOSPITALIZATION

SKILLED NURSING FACILITY CARE*

BLOOD

HOSPICE CARE

5

Medicare Supplement Application

Plan F

Medicare Parts A & B

Plan F

Other Benefits - Not Covered by Medicare

Services Medicare Pays Plan Pays You Pay

HOME HEALTH CARE -

Services Medicare Pays Plan Pays You Pay

FOREIGN TRAVEL –

be healthy.

live healthy.

23

Please answer all questions: Medicare (Part B) - Medical Services - Per Calendar Year Plan F

Services Medicare Pays Plan Pays You Pay

MEDICAL EXPENSES -

PART B EXCESS CHARGES

(Above Medicare Approved Amounts)

Why ^Notes

F ^K ^L ^M ^N

Please answer all questions: Medicare (Part B) - Medical Services - Per Calendar Year ^{Plan F}