MedicareBlue SupplementSM

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Choose from five Medicare Supplement Plans

enrollment kit

Supplement

MedicareBlue Supplement

SM

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plan I can depend on.”

Get reliable, secure coverage from a company you can trust.

MedicareBlue Supplement

^SM

PRODUCT GUIDE

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As a unique individual with specific health care coverage needs, it’s important to find the right combination of benefits, premiums and out-of-pocket costs to fit your needs.

Let Wellmark help you find the plan that will work best for you.

Are you looking for . . .

Comprehensive coverage with the greatest benefit package? Take a look at

›PLAN F

If you’re looking for a plan that’s hassle-free, Plan F may be for you. Just pay your

monthly premiums and Plan F takes care of the rest, including any differences with Part B excess charges.

Comprehensive coverage with a lower price tag? Take a look at

›HIGH DEDUCTIBLE PLAN F

This plan may be the one for you if you’re looking for the same comprehensive coverage as regular Plan F at a fraction of the premium price. Once you meet the annual deductible, this plan steps in and takes care of the rest, just like regular Plan F. Also, if your needs change, you have the flexibility to move to the regular Plan F without answering health questions after one year during the Annual Election Period.

Lower cost monthly premiums in exchange for small copays? Take a look at

›PLAN N

If you’re used to a more traditional employer-sponsored health plan, then Plan N may be just right for you. With this plan, you pay less in monthly premiums in exchange for small copays of up to $20 for office visits and up to $50 for emergency room visits¹.

Broad benefits with a lower premium? Take a look at

›PLAN D

You may find that Plan D is the perfect fit for you if you visit a doctor or hospital that accepts Medicare and you don’t mind paying the Part B deductible.

Basic benefits and guaranteed acceptance? Take a look at

›PLAN A

You don’t need to worry about being denied coverage from Wellmark with this plan. Wellmark guarantees coverage with Plan A, so regardless of any health issues you may have, you’ll be covered by this plan.

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Standardized plans don’t mean

standardized perks

Get more from your Medicare supplement coverage when you choose Wellmark.

Who doesn’t love to get the most for their money? When you choose Wellmark, in addition to receiving the standard Medicare supplement benefits, you can count on:

S TABILIT Y AND SECURIT Y, INCLUDE D WITH EVE RY PL AN . As a Wellmark member, you can have confidence in your coverage knowing we’re working hard to keep premiums as stable as possible.

ACCE SS TO E XCLUSIVE DISCOUNTS. Members can use the Blue365® discount program to access special discounts on vision and hearing services, fitness resources, travel and more.

HOMEG ROWN CUS TOME R SE RVICE . When you call, you know you can trust the voice on the other end of the phone. We live and work right here in Iowa, and are proud to have been serving Iowans for 75 years.

HE ALTHY ADVANTAG E S. If you live a healthy lifestyle, you may be eligible for preferred monthly premiums³. FRE E DOM OF CHOICE . Visit any Medicare-

participating doctor or hospital you want with no referrals and relax knowing you’re covered if you’re traveling across the state or across the country.

coverage have already chosen

Wellmark

²

.

Contact us with questions

or for more information.

We’re here to help find a

plan that’s right for you.

Call a Wellmark representative at 800-336-0505

(TTY hearing

impaired call 711)

8 a.m. to 5 p.m.,

Monday - Friday,

Central time

Visit us online at:

Wellmark.com/Medicare Contact your authorized Wellmark representative

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Blue Cross^®, Blue Shield^®, and the Cross^® and Shield^® Symbols and Blue365^® are registered marks, and MedicareBlue Supplement^SM is a service mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

This is a solicitation of insurance. MedicareBlue Supplement plans presented in this brochure are specific to Wellmark Blue Cross and Blue Shield of Iowa and can only be purchased by Iowa residents. Enrollment and coverage in a MedicareBlue Supplement insurance plan is with Wellmark Blue Cross and Blue Shield of Iowa, an independent licensee of the Blue Cross and Blue Shield Association. MedicareBlue Supplement insurance plans and the Blue365 member discount program are not connected with or endorsed by the U.S. government or the federal Medicare program. These policies have exclusions and limitations. For costs and complete details of coverage, contact Wellmark Blue Cross and Blue Shield of Iowa or your authorized independent agent.

1 The copay of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

2 Source: NAIC data trend, 2013.

3 Eligiblity for preferred premiums is dependent upon your answers to health questions on the application.

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Benefit Chart of Medicare Supplement Plans Sold for Effective Dates

on or after January 1, 2015

This chart shows the benefits included in each of the standard Medicare supplement plans.

Every company must make Plan “A” available. Some plans may not be available in your state.

Basic Benefits

Hospitalization: Part A coinsurance plus 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. Plans K, L and N require members to pay a portion of Part B coinsurance or copayments.

Blood: First three pints of blood each year.

Hospice: Part A coinsurance.

Standard Medicare Supplement Plans

A B C D F F ^HD G

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance ^HD

Basic, including 100% Part B coinsurance Skilled Nursing

Facility Coinsurance

Skilled Nursing Facility

Coinsurance

Coinsurance Part A Deductible Part A Deductible 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 Foreign Travel Emergency Plans shaded in gray are offered by Wellmark Blue Cross and Blue Shield of Iowa.

HD Plan F also has an option called a High Deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from High Deductible Plan F will not begin until out-of-pocket expenses exceed $2,180.

Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do 2015 Outlines of Coverage

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Standard Medicare Supplement Plans continued...

K L M N

Basic Benefits 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

75% Part A Deductible

50% Part A Deductible

Part A Deductible Part B Deductible

Part B Excess (100%)

Foreign Travel Emergency Foreign Travel

Emergency

Foreign Travel Emergency Out-of-pocket limit

$4,940; plan pays at 100% after limit is reached

Out-of-pocket limit

$2,470; plan pays at 100% after limit is reached

Plans shaded in gray are offered by Wellmark Blue Cross and Blue Shield of Iowa.

See Outlines of Coverage for details and explanations of the plans offered by Wellmark Blue Cross and Blue Shield.

Premiums effective January 1, 2015, for Iowa residents.

Applicants should refer to the 2015 MedicareBlue Supplement application to determine eligibility for preferred or standard premiums.

Age Plan D Plan F High Deductible

Plan F Plan N

Male Female Male Female Male Female Male Female Age 64 & Under $203.40 $179.90 $217.20 $192.10 $114.60 $101.40 $162.70 $143.90

Age 65 $113.20 $100.10 $120.90 $106.90 $63.80 $56.30 $90.50 $80.10

Age 66 $116.90 $103.30 $124.70 $110.20 $65.70 $58.20 $93.40 $82.60

Age 67 $120.40 $106.50 $128.70 $113.80 $67.90 $59.90 $96.30 $85.20

Age 68 $124.10 $109.80 $132.60 $117.20 $69.90 $61.90 $99.20 $87.80

Age 69 $128.20 $113.30 $136.70 $120.90 $72.20 $63.80 $102.40 $90.60

Age 70 $131.60 $116.30 $140.60 $124.20 $74.10 $65.50 $105.20 $93.00

Age 71 $142.80 $126.20 $152.50 $134.90 $80.50 $71.10 $114.20 $101.00

Age 72 $147.10 $130.00 $157.10 $138.80 $82.80 $73.30 $117.60 $104.00

Age 73 $151.40 $133.90 $161.70 $143.00 $85.30 $75.40 $121.10 $107.10

Age 74 $156.00 $138.00 $166.60 $147.40 $87.90 $77.70 $124.80 $110.40

Age 75 $160.70 $142.00 $171.60 $151.80 $90.50 $80.00 $128.60 $113.70

Age 76 $168.50 $148.90 $179.90 $159.10 $94.90 $83.90 $134.80 $119.10

Age 77 $176.90 $156.40 $188.80 $167.00 $99.60 $88.10 $141.40 $125.10

Age 78 $186.10 $164.50 $198.80 $175.80 $104.90 $92.70 $148.90 $131.70 Age 79 $195.30 $172.60 $208.60 $184.40 $110.10 $97.30 $156.40 $138.20 Age 80 $205.20 $181.40 $219.10 $193.80 $115.60 $102.10 $164.10 $145.20 Age 81 & Over $226.70 $200.40 $242.10 $214.00 $127.70 $112.90 $181.30 $160.30 Premiums are based upon the most currently available Medicare deductible and

cost-sharing amounts. These premiums are subject to changes in the Medicare amounts for covered cost-sharing and deductibles.

If you are applying for non-guaranteed issue Plans D, F, High Deductible Plan F, or N during the following periods you do not have to answer health questions on the application: (1) within six months following the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B or (2) during a Guaranteed Issue Rights period.

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Age Plan D Plan F High Deductible

Male Female Male Female Male Female Male Female Age 64 & Under $223.70 $197.90 $238.90 $211.30 $126.10 $111.50 $179.00 $158.20

Age 65 $124.50 $110.10 $132.90 $117.60 $70.20 $62.00 $99.60 $88.10

Age 66 $128.50 $113.60 $137.20 $121.20 $72.30 $64.00 $102.80 $90.80

Age 67 $132.50 $117.10 $141.50 $125.20 $74.70 $65.90 $106.00 $93.70

Age 68 $136.50 $120.80 $145.90 $128.90 $76.90 $68.10 $109.20 $96.60

Age 69 $141.00 $124.60 $150.40 $133.00 $79.40 $70.20 $112.70 $99.70

Age 70 $144.70 $127.90 $154.60 $136.70 $81.50 $72.10 $115.80 $102.30

Age 71 $157.10 $138.90 $167.80 $148.40 $88.50 $78.20 $125.70 $111.10

Age 72 $161.80 $143.00 $172.80 $152.70 $91.10 $80.60 $129.40 $114.40

Age 73 $166.60 $147.30 $177.90 $157.30 $93.80 $83.00 $133.20 $117.80

Age 74 $171.60 $151.80 $183.30 $162.10 $96.70 $85.50 $137.30 $121.40

Age 75 $176.80 $156.20 $188.80 $167.00 $99.60 $88.00 $141.40 $125.00

Age 76 $185.30 $163.80 $197.80 $175.00 $104.40 $92.30 $148.20 $131.00 Age 77 $194.60 $172.10 $207.70 $183.70 $109.60 $96.90 $155.60 $137.60 Age 78 $204.70 $180.90 $218.70 $193.40 $115.30 $102.00 $163.80 $144.80 Age 79 $214.80 $189.90 $229.40 $202.90 $121.10 $107.00 $172.00 $152.00 Age 80 $225.80 $199.60 $241.00 $213.20 $127.20 $112.40 $180.50 $159.70 Age 81 & Over $249.40 $220.40 $266.30 $235.40 $140.50 $124.20 $199.50 $176.40

Age Plan A Plan D Plan F High Deductible

Male Female Male Female Male Female Male Female Male Female Age 64 & Under $255.40 $225.80 $233.80 $206.80 $258.20 $228.40 $134.30 $118.80 $187.10 $165.40 Age 65 $108.50 $95.90 $130.10 $115.10 $143.70 $127.10 $74.70 $66.00 $104.10 $92.10 Age 66 $112.00 $99.10 $134.30 $118.80 $148.30 $131.00 $77.00 $68.20 $107.40 $94.90 Age 67 $115.50 $102.20 $138.50 $122.40 $153.00 $135.30 $79.50 $70.20 $110.70 $97.90 Age 68 $119.00 $105.30 $142.70 $126.20 $157.70 $139.30 $81.90 $72.50 $114.10 $101.00 Age 69 $122.80 $108.60 $147.40 $130.20 $162.60 $143.80 $84.60 $74.70 $117.80 $104.20 Age 70 $126.10 $111.40 $151.30 $133.70 $167.10 $147.70 $86.80 $76.80 $121.00 $107.00 Age 71 $136.90 $121.00 $164.20 $145.10 $181.30 $160.40 $94.30 $83.30 $131.30 $116.10 Age 72 $141.00 $124.70 $169.10 $149.50 $186.80 $165.10 $97.00 $85.90 $135.20 $119.50 Age 73 $145.10 $128.30 $174.10 $153.90 $192.20 $170.00 $99.90 $88.40 $139.20 $123.10 Age 74 $149.60 $132.20 $179.30 $158.60 $198.10 $175.20 $103.00 $91.10 $143.50 $126.90 Age 75 $154.00 $136.20 $184.80 $163.30 $204.00 $180.50 $106.10 $93.70 $147.80 $130.70 Age 76 $161.50 $142.70 $193.70 $171.20 $213.80 $189.20 $111.20 $98.30 $154.90 $136.90 Age 77 $169.50 $149.80 $203.40 $179.90 $224.50 $198.60 $116.70 $103.20 $162.60 $143.80 Age 78 $178.40 $157.80 $213.90 $189.10 $236.40 $209.00 $122.80 $108.70 $171.20 $151.40 Age 79 $187.20 $165.50 $224.50 $198.50 $248.00 $219.30 $129.00 $114.00 $179.80 $158.80 Age 80 $196.70 $174.00 $236.00 $208.60 $260.50 $230.40 $135.40 $119.70 $188.70 $167.00 Age 81 & Over $217.30 $192.10 $260.70 $230.40 $287.80 $254.40 $149.60 $132.30 $208.50 $184.30 You do not have to answer health questions if you apply for Plan A.

Premiums are based upon the most currently available Medicare deductible and cost-sharing amounts. These premiums are subject to changes in the Medicare amounts for covered cost-sharing and deductibles.

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Premium Information

Wellmark Blue Cross and Blue Shield can only raise your premium if we raise the premium for all policies like yours in this state. When we change the premium upon our implementation of a new table of premiums or a change in Medicare’s benefit structure, your new premium will be based upon your age at the effective date of the premium change. If we do change your premium, we will notify you at least 30 days in advance. However, if you are applying for coverage within 60 days of a premium change with an effective date prior to the premium change, Wellmark will provide notice of the new premium within a reasonable period of the time after the enrollment of your application.

Disclosures

Use this outline to compare benefits and premiums among policies.

This outline shows benefits and premiums 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 and premiums.

Read Your Policy Very Carefully

This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.

Right to Return Policy

If you find that you are not satisfied with your policy, you may return it to:

Wellmark Blue Cross and Blue Shield of Iowa P.O. Box 14527

Des Moines, IA 50306-3527

If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

Policy Replacement

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

Notice

This policy may not fully cover all of your medical costs.

Neither Wellmark Blue Cross and Blue Shield of Iowa nor its agents 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

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. Wellmark Blue Cross and Blue Shield 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.

You do not have to answer health questions if you apply for Plan A.

Age Plan A Plan D Plan F High Deductible

Male Female Male Female Male Female Male Female Male Female Age 64 & Under $281.00 $248.40 $257.20 $227.50 $284.10 $251.20 $147.70 $130.60 $205.80 $181.90 Age 65 $119.40 $105.50 $143.10 $126.60 $158.10 $139.80 $82.20 $72.60 $114.50 $101.30 Age 66 $123.20 $109.00 $147.80 $130.60 $163.10 $144.10 $84.70 $75.00 $118.10 $104.40 Age 67 $127.10 $112.40 $152.30 $134.70 $168.30 $148.80 $87.50 $77.20 $121.80 $107.70 Age 68 $130.90 $115.80 $157.00 $138.80 $173.40 $153.30 $90.10 $79.70 $125.50 $111.00 Age 69 $135.00 $119.50 $162.10 $143.20 $178.80 $158.20 $93.10 $82.20 $129.50 $114.60 Age 70 $138.70 $122.60 $166.40 $147.00 $183.90 $162.50 $95.40 $84.50 $133.10 $117.70 Age 71 $150.60 $133.10 $180.60 $159.70 $199.50 $176.40 $103.70 $91.60 $144.50 $127.70 Age 72 $155.10 $137.10 $186.00 $164.40 $205.50 $181.60 $106.70 $94.40 $148.80 $131.50 Age 73 $159.70 $141.20 $191.50 $169.30 $211.50 $187.00 $109.90 $97.20 $153.20 $135.40 Age 74 $164.60 $145.50 $197.20 $174.50 $217.90 $192.70 $113.30 $100.20 $157.80 $139.60 Age 75 $169.40 $149.90 $203.20 $179.60 $224.40 $198.50 $116.70 $103.10 $162.60 $143.70 Age 76 $177.70 $157.00 $213.00 $188.30 $235.20 $208.10 $122.30 $108.20 $170.40 $150.60 Age 77 $186.50 $164.80 $223.70 $197.90 $247.00 $218.40 $128.40 $113.50 $178.90 $158.20 Age 78 $196.30 $173.60 $235.30 $208.00 $260.10 $229.90 $135.10 $119.50 $188.30 $166.50 Age 79 $205.90 $182.10 $246.90 $218.30 $272.80 $241.20 $141.90 $125.40 $197.70 $174.70 Age 80 $216.30 $191.40 $259.60 $229.40 $286.60 $253.50 $149.00 $131.60 $207.50 $183.70 Age 81 & Over $239.00 $211.30 $286.70 $253.40 $316.60 $279.90 $164.60 $145.50 $229.30 $202.70 Premiums effective January 1, 2015, for Iowa residents.

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Medicare (Part A) Hospital Services Per Benefit Period

Services Medicare Pays Plan A Pays You Pay

Hospitalization¹

Semiprivate room and board, general nursing and miscellaneous services and supplies.

First 60 days All but $1,260 $0 $1,260

(Part A deductible)

61st thru 90th day All but $315 a day $315 a day $0

91st day and after

› While using 60 lifetime reserve days All but $630 a day $630 a day $0

› Once lifetime reserve days are used:

• Additional 365 days $0 100% of Medicare

eligible expenses $0²

• Beyond the additional 365 days $0 $0 All costs

Skilled Nursing Facility Care ¹

You must meet Medicare’s requirements, including having been in a hospital for at least three 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 $157.50 a day $0 Up to $157.50 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 requirements, including doctor’s certification of terminal illness.

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

Medicare copayment/

coinsurance $0

1 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.

2 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 “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.

Medicare (Part B) Medical Services Per Calendar Year

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 $147 of Medicare approved amounts ³

$0 $0 $147

(Part B deductible) Remainder of Medicare approved

amounts

Generally 80% Generally 20% $0

Part B Excess Charges

(Above Medicare approved amounts)

$0 $0 All costs

Blood

First 3 pints $0 All costs $0

Next $147 of Medicare approved amounts ³

$0 $0 $147

amounts

80% 20% $0

Clinical Laboratory Services

TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

3 Once you have been billed $147 of Medicare approved amounts for covered services, your Part B deductible will have been met for the calendar year.

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Services Medicare Pays Plan D Pays You Pay

Hospitalization ¹

First 60 days All but $1,260 $1,260

(Part A deductible)

$0

91st day and after

eligible expenses

$0 ²

21st thru 100th day All but $157.50 a day Up to $157.50 a day $0

Blood

Hospice Care

You must meet Medicare’s requirements, including doctor’s certification of

terminal illness.

All but very limited copayment/

coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/

coinsurance

$0

Medicare Parts A & B

Home Health Care

MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment:

› First $147 of Medicare approved amounts ³

$0 $0 $147

(Part B deductible)

› Remainder of Medicare approved amounts

80% 20% $0

Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

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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

$0 $0 $147

amounts

$0 $0 All costs

Blood

$0 $0 $147

amounts

80% 20% $0

100% $0 $0

Durable Medical Equipment:

$0 $0 $147

(Part B deductible)

80% 20% $0

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

› Remainder of charges $0 80% to a lifetime

maximum benefit of

$50,000

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

Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

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Services Medicare Pays Plan F Pays You Pay

(Part A deductible)

$0

91st day and after

eligible expenses

$0 ²

Blood

Hospice Care

You must meet Medicare’s requirements, including doctor’s certification of

terminal illness.

Medicare copayment/

coinsurance

$0

$0 $147

(Part B deductible)

$0 Remainder of Medicare approved

amounts

$0 100% $0

Blood

$0 $147

(Part B deductible)

amounts

80% 20% $0

100% $0 $0

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100% $0 $0

$0 $147

(Part B deductible)

$0

80% 20% $0

Foreign Travel

maximum benefit of

$50,000

Services Medicare Pays After you pay $2,180

deductible Plan F^HD

Pays You Pay

Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1,260 $1,260 (Part A deductible) $0

91st day and after

eligible expenses $0 ²

Blood

Hospice Care

Medicare copayment/

coinsurance $0

HD This high deductible plan pays the same benefits as Plan F after you have paid a calendar year $2,180 deductible.

Benefits from the High Deductible Plan F will not begin until out-of-pocket expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

2 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

“Basic Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference

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Services Medicare Pays After you pay

$2,180 deductible

Plan F^HD Pays You Pay Medical Expenses

$0 $147

(Part B deductible)

amounts

$0 100% $0

Blood

$0 $147

(Part B deductible)

amounts

80% 20% $0

100% $0 $0

deductible

Plan F^HD Pays You Pay Home Health Care

MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies

100% $0 $0

$0 $147

(Part B deductible)

$0

80% 20% $0

deductible Plan F^HD

Pays You Pay

Foreign Travel

maximum benefit of

$50,000

HD This high deductible plan pays the same benefits as Plan F after you have paid a calendar year

$2,180 deductible. Benefits from the High Deductible Plan F will not begin until out-of-pocket expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

NOTE: You may move to Wellmark’s regular Plan F from High Deductible Plan F without answering health questions after twelve consecutive months of enrollment on High Deductible Plan F. You may only move during the Annual Enrollment Period, Oct. 15 – Dec. 7, for a Jan. 1 effective date.

HDThis high deductible plan pays the same benefits as Plan F after you have paid a calendar year $2,180 deductible. Benefits from the High Deductible Plan F will not begin until out-of- pocket expenses are $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

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Services Medicare Pays Plan N Pays You Pay

(Part A deductible)

$0

91st day and after

eligible expenses

$0 ²

Blood

Hospice Care

Medicare copayment/

coinsurance

$0

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.

$0 $0 $147

amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit.

The copayment of up to $50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit.

The copayment of up to

$50 is waived if the member is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

$0 $0 All costs

Blood

$0 $0 $147

amounts

80% 20% $0

100% $0 $0

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quarter, semi-annual calendar year, or calendar year basis. For example, a monthly premium would be for the first day of a month through the last day of such month. A quarterly payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual premium would be for January 1 through December 31 of the applicable year.

The amount of your periodic premium payment will change as provided in the policy and from time to time based on changes in your coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), your age, or other factors that require adjustments to the total premium. These changes may occur at times other than an annual or other policy renewal.

If you elected to authorize automatic premium withdrawals from a deposit account, the automatic withdrawal will change periodically to correspond with the applicable premium. Your authorization for automatic premium withdrawals shall include authorization for

automatic withdrawal of any changed amount unless you call or provide your bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If you call your bank to stop payment, you may be required to provide a written request within fourteen (14) days after your call. You will be responsible for any fee assessed by your bank for stop-payment orders that you make.

MedicareBlue Supplement^SM is a Medicare Supplement insurance plan.

MedicareBlue Supplement^SM is not connected with or endorsed by the U.S. government or the federal Medicare program.

100% $0 $0

$0 $0 $147

(Part B deductible)

80% 20% $0

Foreign Travel

maximum benefit of

$50,000

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Already Enrolled: 800-245-6106 TTY hearing impaired users call 711

Blue Cross^®, Blue Shield^®, and the Cross^® and Shield^® Symbols are registered marks, and MedicareBlue Supplement^SM is a service mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Wellmark Blue Cross and Blue Shield of Iowa is an Independent Licensee of the Blue Cross and Blue Shield Association.

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Address Information:

Physical Address (Include Street, Bldg Name/No., Apt. No.) County Name

City State Zip

If mailing address is NOT the same as the physical address listed above, please complete mailing address information.

Mailing Address (Include Street, Bldg Name/No., Apt. No.) PO Box

City State Zip

B. Tell us about your tobacco usage.

Note: You are required to answer this question. However, if you are applying during a guaranteed issue rights period or during your six-month Medicare Supplement open enrollment period only the Non-Tobacco user premium will apply.

c Yes c No

B1.

Have you used tobacco during the 12 months immediately preceding the effective date of this application?

A. Tell us about yourself.

Requested Effective Date _______/_______/_________

Applicant Name (First, Middle, Last)

Date of Birth (mm/dd/yyyy)

________/________/___________

Gender

c Male c Female

Social Security Number

Daytime Phone ( )

E-mail Address (optional)

C. Provide us with your Medicare information.

Please take out your Medicare ID card and use it to assist

you in completing this section of the application. Name: ________________________________

Medicare Number: Sex (M/F): _______

Fill in the blank spaces so they match your red, white, and blue Medicare ID card exactly.

______-_____-_______

Is Entitled to: Effective Date (mm/dd/yyyy):

HOSPITAL (Part A) ______/______/________

MEDICAL (Part B) ______/______/________

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C. Provide us with your Medicare information, cont’d.

c Yes c No

C1.

Did you turn age 65 in the last 6 months?

c Yes c No

C2.

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

If yes, what is your Part B effective date (mm/dd/yyyy)? _______/_______/_______

c Yes c No

C3.

Are you applying for a plan effective date within 6 months after:

• your Medicare Part B effective date and turning 65 (or older)?

Or

• the first day of the month in which you turn age 65 (or the first day of the month prior to the month in which you turn age 65 if your birth date is the first day of the month) and are currently enrolled in Medicare Part B?

STOP

If you answered YES to question C3 above, you are within your Medicare Supplement Open Enrollment Period and your acceptance is guaranteed. You do not have to answer health questions and can proceed to Section G of the application to select your plan. You are eligible for Plans A, D, F, High Deductible F and N. To determine your monthly premium amount, refer to the MedicareBlue Supplement - Preferred Non-Tobacco premium table in the Outline of Coverage for Plans D, F, High Deductible F and N, and to the MedicareBlue Supplement - Standard Non-Tobacco premium table in the Outline of Coverage for Plan A.

If you answered NO to question C3 above, please continue to Section D to determine if your acceptance is guaranteed.

D. Review the following loss of coverage situations to determine if your

acceptance is guaranteed.

If your previous coverage terminated or ceased to provide some benefits more than 63 days prior to the date of this application, you are outside of your guaranteed issue rights period. You must complete the entire application including answering the health questions. Please go to Section E to determine the plan(s) for which you are eligible.

If you lost or are losing other health insurance coverage and received a notice from your previous insurer and/or

employer saying that you are eligible for guaranteed issue of a Medicare Supplement insurance policy, or that you have certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare Supplement plans.

If one of these situations applies to you, check the appropriate box at the left and then provide the date your coverage was effective and/or the date your coverage will end (mm/dd/yyyy). Check one only.

c Applies to me

D1.

I am enrolled in a Medicare Advantage Plan, and my plan is leaving Medicare or will no longer be providing coverage in my area, or I have moved out of my plan’s service area.

If applicable, please provide the date coverage will end _______/_______/_________

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c Applies to me

D2.

I have Original Medicare and an employer group health plan that pays after Medicare pays and that plan has stopped providing some or all health benefits (only applies to involuntary loss of coverage).

If this applies to you, check the option that describes your situation below:

c a. Retiree coverage is being terminated by the employer c b. COBRA eligibility has expired

c c. Group coverage with under 20 employees is ending c d. After 30 months of coverage for end stage renal disease

c Applies to me

D3.

I have Original Medicare and a Medicare Select policy, and I am moving out of the Medicare Select policy’s service area.

c Applies to me

D4.

I joined a Medicare Advantage Plan or Programs for All-Inclusive Care for the Elderly (PACE) when I was first eligible for Medicare Part A or B at age 65, and within the first year of joining, I want to disenroll. (Trial Right)

If applicable, please provide the date coverage was effective _______/_______/_________;

and the date coverage will end _______/_______/_________

c Applies to me

D5.

I canceled my Medicare Supplement policy to join a Medicare Advantage Plan (or to switch to a Medicare Select policy) for the first time, have been in the plan less than one year, and want to re-enroll in my original Medicare Supplement policy or my original Medicare Supplement policy is no longer available. (Trial Right).

If applicable, please provide the date coverage was effective _______/_______/_________;

and the date coverage will end _______/_______/_________

c Applies to me

D6.

I have Medicare Supplement insurance, and I am losing my coverage because the insurance company went bankrupt, or my coverage is ending through no fault of my own.

If applicable, please provide the date coverage will end _______/_______/_______

c Applies to me

D7.

I am leaving a Medicare Advantage Plan or a Medicare Supplement policy because I have been notified the insurance company has violated a provision of its contract with me or it misled me.

If applicable, please provide the date coverage will end _______/_______/_______

STOP

If you checked any of the situations above and your coverage did not end (or cease to provide some benefits) more than 63 days before the date of this application, your acceptance may be guaranteed. You do not have to answer health questions and can proceed to Section G of the application to select your plan. You are eligible for Plans A, D, F, High Deductible F and N. To determine your monthly premium amount, refer to the MedicareBlue Supplement - Preferred Non-Tobacco premium table in the Outline of Coverage for Plans D, F, High Deductible F and N, and to the MedicareBlue Supplement - Standard Non-Tobacco premium table in the Outline of Coverage for Plan A.

If none of the situations above apply to you, you must complete the entire application including answering the health questions. Please continue to Section E to determine the plan(s) for which you are eligible.

D. Review the following loss of coverage situations to determine if your

acceptance is guaranteed, cont’d.

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E. Answer the following health questions to determine the plan(s) for which

you are eligible.

c Yes c No

E1.

Do any of the following situations apply to you?

• Currently in the hospital or have been an inpatient within the last 90 days (excluding outpatient or overnight/observation beds)

• Receive or require dialysis

• Require bottled oxygen or an oxygen concentrator to help you breathe (this does not include the use of a CPAP machine for Sleep Apnea)

c Yes c No

E2.

In the last two years, have you received medical advice, or testing in preparation for any of the following surgical procedures? (If the actual surgical procedure has already been completed, you may respond ‘no’ to this question.)

• Heart or bypass surgery (this includes having a pacemaker or defibrillator implanted, but not updates to an existing pacemaker such as replacement of the battery)

• Angioplasty or vascular surgery

• Back or spine surgery

• Joint replacement

• Surgery for any form of cancer

• Surgery to remove any type of tumor

• Amputation due to disease

• Organ transplant

c Yes c No

E3.

In the last two years, have you received medical advice, treatment, or prescription medications from a health care professional for any of the following conditions:

• Liver problems related to Cirrhosis, or Hepatitis B or C

• Any form of cancer including Leukemia, Lymphoma, or Melanoma (except basal cell and squamous cell skin cancer)

• Stroke or Transient Ischemic Attack (TIA)

• Amyotrophic Lateral Sclerosis (ALS)

• Multiple Sclerosis (MS)

• Acquired Immune Deficiency Syndrome (AIDS) or tested positive for HIV

• Kidney or Renal Disease related to Chronic Renal Failure

• Paraplegia or Quadriplegia STOP

If you answered YES to any of the questions in Section E above, you are only eligible for Plan A at the Standard premium. To determine your monthly premium amount, refer to the MedicareBlue Supplement – Standard premium tables in the Outline of Coverage. Please go to Section G and select Plan A.

If you answered NO to all of the questions in Section E above, you are eligible for Plans A, D, F, High Deductible F and N at the Standard premium. Please proceed to Section F to determine if you qualify for Preferred premiums.

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Circulatory Conditions

• Aneurysm

• Artery Blockage

• Atrial Fibrillation or Flutter

• Cardiomyopathy

• Carotid Artery Disease

• Congestive Heart Failure

• Coronary Artery Disease

• Heart Attack

• Peripheral Artery Disease

• Ventricular Tachycardia

• Deep vein thrombosis or blood clot(s) in vein

• Hemophilia

Metabolic Conditions

• Diabetes with one or more complications (such as:

Neuropathy/nerve damage, Kidney disease, or Retinopathy) • Diabetes requiring an insulin

pump

Substance Abuse

• Alcohol Abuse or Alcoholism

• Drug Abuse or Use of Illegal Drugs

Respiratory Conditions

• Chronic Obstructive Pulmonary Disease (COPD)

• Emphysema

• Chronic Bronchitis

• Chronic Asthma

• Chronic Interstitial Lung Disease

• Chronic Pulmonary Fibrosis

• Cystic Fibrosis

• Sarcoidosis

• Bronchiectasis Kidney Conditions

• Polycystic Kidney Disease

• Renal Artery Stenosis

• Chronic Renal Insufficiency Gastrointestinal Conditions

• Chronic Pancreatitis

• Esophageal Varices

Musculoskeletal Conditions

• Amputation Due to Disease

• Rheumatoid Arthritis (RA)

• Spinal Stenosis

• Osteoporosis with fracture

Organ Transplant

• Organ Transplant

• Bone Marrow Transplant Auto-immune Disorders/

Connective Tissue Disorders

• Scleroderma

• Systemic Lupus Erythematosus (SLE) Psychological /Mental Conditions

• Bipolar or Manic Depressive

• Major Depressive Disorder

• Schizophrenia

• Anorexia Nervosa Eye Condition

• Retinopathy

Neurological/Nervous System Conditions

• Hemiplegia – paralyzed on one side

• Alzheimer’s Disease, Dementia or Cognitive disorders

• Parkinson’s Disease

• Myasthenia Gravis

• Seizure disorders

c Yes c No

F1.

In the last two years, have you been diagnosed, treated, or been prescribed medication by a health care professional for any of the conditions listed above? You must also respond ‘yes’ to this question if you are currently receiving treatment and/or taking a medication to treat any of the conditions listed. (If you are uncertain as to whether a listed condition applies to you, please consult with your physician as to your specific diagnosis.)

STOP

If you answered YES to question F1 above, you qualify for Plans A, D, F, High Deductible F and N at the Standard premium. To determine your monthly premium amount, refer to the MedicareBlue Supplement – Standard premium tables in the Outline of Coverage. Please proceed to Section G and select your plan.

If you answered NO to question F1 above, you qualify for Plans D, F, High Deductible F and N at the Preferred

premium. To determine your monthly premium amount, refer to the MedicareBlue Supplement – Preferred premium tables in the Outline of Coverage. You are also eligible for Plan A at the Standard premium. Please proceed to Section G and select your plan.

F. Review the list of health conditions and answer the following health

question to determine if you qualify for Preferred premiums.

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G. Choose the plan for which you are applying.

Please answer all questions.

(Answer questions below by marking YES or NO with an “X”.) To the best of your knowledge:

c Yes c No

c Yes c No c Yes c No

H1.

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.)

If yes,

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

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

c Yes c No

c Yes c No c Yes c No

H2.

Have you had coverage from any Medicare plan other than Original Medicare within the past 63 days (this includes a Medicare Advantage plan, or a Medicare HMO or PPO)?

If yes,

(a) Fill in your start and end dates below. If you are still covered under this plan, leave “END”

blank.

START _______/_______/_______ END _______/_______/_______

(b) With what insurance company, and what kind of policy?

__________________________________________________________________

(c) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy? If yes, you must complete “Notice to Applicant regarding replacement of Medicare Supplement Insurance or Medicare Advantage” on the last page of this application.

(d) Was this your first time in this type of Medicare plan?

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

(f) If yes, with what insurance company was your Medicare Supplement policy?

__________________________________________________________________

c Yes c No

H3.

Do you have another Medicare Supplement policy in force with any carrier including Wellmark?

If yes,

(a) With what insurance company, and what plan do you have?

__________________________________________________________________

(b) Do you intend to replace your current Medicare Supplement policy with this policy?

If yes, you must complete “Notice to Applicant regarding replacement of Medicare Supplement Insurance or Medicare Advantage” on the last page of this application.

(c) If yes, What is the paid-to or expiration date of your policy? _______/_______/_______

H. Answer the following questions about your past and current coverage.

Check the MedicareBlue Supplement plan for which you are applying:

c Plan A c Plan D c Plan F c High Deductible Plan F c Plan N

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c

I1.

Direct Bill. On what basis? c Quarterly c Semi-annually c Annually

c

I2.

Use billing information on file with Wellmark (Available only for those with current Wellmark individual coverage) c

I3.

Automatic Account Withdrawal from Applicant’s account

c

I4.

Automatic Account Withdrawal from account other than Applicant’s

I. Choose your method of payment.

Select how you would like to pay for your MedicareBlue Supplement premiums from one of the options below. Billing periods are based on a calendar year. Please do not send payment with this application. If the Bank Account Holder is not present to sign the application, you will need to complete and submit an Automatic Payment Authorization Form (M-5779).

H. Answer the following questions about your past and current coverage,

cont’d.

c Yes c No

H4.

Have you had coverage under any other health insurance within the past 63 days?

(This includes, an employer, union, or individual plan.) If yes,

(a) With what insurance company, what kind of policy, and employer name (if applicable)?

_____________________________________________________________________

(b) What are your dates of coverage under the other policy? If you are still covered under the other policy, leave “END” blank.

START _______/_______/_______ END _______/_______/_______

Payer’s Name:

Payer’s Mailing Address (Include Street, Bldg Name/No., Apt. No.) PO Box

City State Zip

Payer’s Billing Information (if different from Applicant’s mailing address):

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If Direct bill is not selected:

As the Bank Account Holder, I hereby authorize Wellmark to make automatic withdrawals from the account shown above (or on the attached voided check below) in the amount of my periodic premium payment as it may be adjusted from time to time. If the undersigned is not the Applicant, I understand and agree that notices of any premium

adjustments when provided to the Applicant shall constitute notice to the undersigned of any such adjustment. I hereby certify that I have read and understand the provisions of the Application Agreement and Certification section. This authorization shall supersede and replace any previous authorization given by me for automatic premium withdrawal.

Bank Account Holder’s Signature (if other than Applicant)_____________________________ Date ____/____/____

You may cancel automatic account withdrawal at any time. However, we need to receive your written notification at least 20 days before your next scheduled withdrawal.

I. Choose your method of payment, cont’d.

If you selected payment method I3 or I4, please complete the following:

On what basis? c Monthly c Quarterly c Semi-annually c Annually Date of withdrawal: c 1st of the month c 5th of the month

From: c Checking c Savings

Attach a voided check in the space designated below Or complete the following information:

Financial Institution Name: ______________________________________________________________

Bank Account Name(s) (exactly as appears on the account): _____________________________________

Financial Institution Routing Number (9 digits): _______________________________________________

Account Number: _____________________________________________________________________

State Code (found on your check on the top right corner above the date--e.g., 78): _____________________

TAPE VOIDED CHECK HErE Or

PrOVIDE FINANCIAL INFOrMATION IN THE SPACES PrOVIDED ABOVE (DO NOT STAPLE Or COVEr LANGUAGE ABOVE & BELOW THIS SPACE)