Medicare Supplement Coverage offered by MyBlue Medigap · 2009-10-27 · If your BMI is You’re in Tier 15 or 16 2 17 to 30 1 31 to 35 2 36 to 40 3 If your BMI is not on the BMI

AMyBlue Medigap — Plans A, C and F

Medicare Supplement Coverage offered by Blue Care Network of Michigan

MyBlue MedigapSM

Outline of Medigap coverage and enrollment application for

Plans A, C and F

My life, My health planbcbsm.com/mybluemedicare

www.bcbsm.com/mybluemedicare

1MyBlue Medigap — Plans A, C and F

MyBlue Medigap premiumsFor MyBlue Medigap plans, certain factors may affect your monthly premium. We base your premium on the area you live in and your age, gender, height, weight, and whether you use tobacco. The charts in this booklet show the monthly cost for Plans A, C and F based on these factors. Please note: If you are submitting your application within six months after you first enrolled for benefits under Medicare Part B or if you are within the guaranteed issue period, your premium will not be affected by your weight, height, tobacco use, health status, claims experience, receipt of health care or medical condition. (In the outline of coverage, we refer to either status as your “Special Enrollment” period.) In all cases, Blue Care Network will not reject your application based on your health status or your age.

2 MyBlue Medigap — Plans A, C and F

An example of how to find your monthly MyBlue Medigap premiumThe following is an example of how to calculate an estimated MyBlue Medigap premium:

Mary selected Plan F.

She’s a 66-year old woman who uses tobacco and her weight is proportionate to her height. As a result, her Body Mass Index is just 25, placing her in Tier 1. Mary lives in the 48037 ZIP code, placing her in Area 1. She’s been enrolled in Medicare Part A and Part B for more than a year.

She did the following to find her monthly MyBlue Medigap premium:

STEP 1 – Because Mary has had Medicare Part B for at least six months, she must look under “Monthly premium rates for individuals enrolled in Medicare Part B six months or longer.” She goes to the tables for Plan F and finds the table for Tier 1.

STEP 2 – Mary looks under the Area 1 columns (ZIP codes beginning with 480 through 485), then scrolls down the AGE column at left to find her age: 66 years.

STEP 3 – She scrolls to the right to find the “Tobacco Users” columns, and within that, “Female.”

STEP 4 – Mary’s monthly premium is $153.89.

Plan F, Tier 1 — Area 1 (480 - 485 ZIP codes)

AGE

Tobacco User Non Tobacco User Female Male Female Male

65 $153.89 $161.97 $142.54 $150.04

66 $153.89 $161.97 $142.54 $150.04

67 $160.04 $170.24 $148.12 $157.54

68 $166.20 $178.90 $153.89 $165.62

69 $172.93 $187.74 $160.04 $173.89

70 $179.28 $196.98 $166.01 $182.36

To find your monthly premium cost, follow these steps:1. Select a plan option: Plan A, C or F.2. Go to page 21 to find your Body Mass Index value.

Your BMI value is based on your height and weight and will tell you which rating tier you belong in:

If your BMI is You’re in Tier

15 or 16 217 to 30 131 to 35 236 to 40 3If your BMI is not on the BMI chart because it is less than 15 or greater than 40, you’re in Tier 3.

3. Using the following tables: If you have enrolled in Medicare Part B within

the last six months or if you are within the guaranteed issue period, use the tables on pages 3 – 5 to find your monthly premium.

If you have been enrolled in Medicare Part B for more than six months and are not within the guaranteed issue period, use the tables on pages 6 – 14.

Instructions:a. Find the plan option that’s right for you and the

Tier in which you belong based on your BMI value.i. If you live in a ZIP code that begins with

480 through 485, you are in Area 1ii. If you live in any other ZIP code in Michigan,

you are in Area 2b. Once you find the correct table, scroll down the

first column to find your age. Your premium will be shown at the right, based on whether you use tobacco and whether you’re male or female.

Your payment optionsYou may make payments through authorized automatic deductions from your bank account or by personal check, money order, or cashier’s check. See the enrollment application in this brochure for details on payment methods. Premium payments are due the fifth day of each month.


Monthly premiums for individuals enrolled in Medicare Part B within the last six months or applying within the guaranteed issue period

MyBlue Medicare Special Enrollment Plan A Rates

Plan A

AGEArea 1 (480 - 485 ZIP) Area 2 (all other)

Female Male Female Male65 $98.37 $103.54 $84.70 $89.16 66 $98.37 $103.54 $84.70 $89.16 67 $102.22 $108.72 $88.01 $93.62 68 $106.20 $114.30 $91.44 $98.42 69 $110.45 $120.01 $95.10 $103.33 70 $114.56 $125.85 $98.65 $108.36 71 $118.54 $131.69 $102.07 $113.39 72 $122.66 $137.79 $105.62 $118.65 73 $126.77 $144.03 $109.16 $124.02 74 $130.89 $150.40 $112.70 $129.51 75 $134.74 $156.64 $116.02 $134.88 76 $137.93 $162.22 $118.76 $139.68 77 $140.32 $165.14 $120.82 $142.20 78 $142.70 $167.93 $122.88 $144.60 79 $145.36 $170.98 $125.16 $147.22 80 $147.88 $173.90 $127.34 $149.74 81 $151.07 $175.63 $130.08 $151.23 82 $154.25 $177.22 $132.82 $152.60 83 $157.31 $178.68 $135.45 $153.85 84 $160.23 $180.01 $137.97 $155.00 85 $163.02 $181.07 $140.37 $155.91 86 $165.67 $182.13 $142.65 $156.83 87 $168.19 $182.93 $144.82 $157.51 88 $170.71 $183.46 $147.00 $157.97 89 $172.84 $183.86 $148.83 $158.31 90 and Over $174.96 $184.12 $150.65 $158.54


Monthly premiums for individuals enrolled in Medicare Part B within the last six months or applying within the guaranteed issue period continued

Plan C



MyBlue Medicare Special Enrollment Plan C Rates


Plan F



MyBlue Medicare Special Enrollment Plan F Rates

Monthly premiums for individuals enrolled in Medicare Part B within the last six months or applying within the guaranteed issue period continued


Plan A, Tier 1

AGE

Area 1 (480 - 485 ZIP codes) Area 2 (all other BCN ZIP codes)Tobacco User Non Tobacco User Tobacco User Non Tobacco User

Female Male Female Male Female Male Female Male65 $106.20 $111.77 $98.37 $103.54 $91.44 $96.24 $84.70 $89.16 66 $106.20 $111.77 $98.37 $103.54 $91.44 $96.24 $84.70 $89.16 67 $110.45 $117.48 $102.22 $108.72 $95.10 $101.16 $88.01 $93.62 68 $114.69 $123.46 $106.20 $114.30 $98.76 $106.30 $91.44 $98.42 69 $119.34 $129.56 $110.45 $120.01 $102.76 $111.56 $95.10 $103.33 70 $123.72 $135.93 $114.56 $125.85 $106.53 $117.05 $98.65 $108.36 71 $127.97 $142.17 $118.54 $131.69 $110.19 $122.42 $102.07 $113.39 72 $132.48 $148.81 $122.66 $137.79 $114.08 $128.14 $105.62 $118.65 73 $136.86 $155.58 $126.77 $144.03 $117.85 $133.97 $109.16 $124.02 74 $141.38 $162.48 $130.89 $150.40 $121.73 $139.91 $112.70 $129.51 75 $145.49 $169.12 $134.74 $156.64 $125.28 $145.62 $116.02 $134.88 76 $148.94 $175.23 $137.93 $162.22 $128.25 $150.88 $118.76 $139.68 77 $151.60 $178.41 $140.32 $165.14 $130.54 $153.63 $120.82 $142.20 78 $154.12 $181.33 $142.70 $167.93 $132.71 $156.14 $122.88 $144.60 79 $157.04 $184.65 $145.36 $170.98 $135.22 $159.00 $125.16 $147.22 80 $159.70 $187.84 $147.88 $173.90 $137.51 $161.74 $127.34 $149.74 81 $163.15 $189.70 $151.07 $175.63 $140.48 $163.34 $130.08 $151.23 82 $166.60 $191.42 $154.25 $177.22 $143.45 $164.83 $132.82 $152.60 83 $169.92 $193.02 $157.31 $178.68 $146.31 $166.20 $135.45 $153.85 84 $173.10 $194.34 $160.23 $180.01 $149.05 $167.34 $137.97 $155.00 85 $176.02 $195.54 $163.02 $181.07 $151.57 $168.37 $140.37 $155.91 86 $178.94 $196.73 $165.67 $182.13 $154.08 $169.40 $142.65 $156.83 87 $181.60 $197.53 $168.19 $182.93 $156.37 $170.09 $144.82 $157.51 88 $184.39 $198.19 $170.71 $183.46 $158.77 $170.66 $147.00 $157.97 89 $186.64 $198.59 $172.84 $183.86 $160.71 $171.00 $148.83 $158.31 90 and Over

$188.90 $198.86 $174.96 $184.12 $162.66 $171.23 $150.65 $158.54

Monthly premiums for individuals enrolled in Medicare Part B six months or longer or not applying within the guaranteed issue period

MyBlue Medigap Plan A, Tier 1 Rates



Plan A, Tier 2

AGE



$207.79 $218.74 $192.46 $202.53 $178.92 $188.35 $165.72 $174.40

Monthly premiums for individuals enrolled in Medicare Part B six months or longer or not applying within the guaranteed issue period continued



Plan A, Tier 3

AGE



$226.68 $238.63 $209.95 $220.95 $195.19 $205.47 $180.78 $190.25



MyBlue Medigap Plan C, Tier 1 Rates


Plan C, Tier 1

AGE



$271.02 $285.30 $251.02 $264.16 $233.37 $245.67 $216.15 $227.46




Plan C, Tier 2

AGE



$298.12 $313.83 $276.12 $290.58 $256.70 $270.23 $237.76 $250.21



Plan C, Tier 3

AGE



$325.22 $342.37 $301.23 $317.00 $280.04 $294.80 $259.38 $272.95




Plan F, Tier 1

AGE



$273.73 $288.16 $253.53 $266.81 $235.70 $248.12 $218.31 $229.74

MyBlue Medigap Plan F, Tier 1 Rates



Plan F, Tier 2

AGE



$301.10 $316.97 $278.89 $293.49 $259.27 $272.93 $240.14 $252.71




Plan F, Tier 3

AGE



$328.48 $345.79 $304.24 $320.17 $282.84 $297.75 $261.97 $275.68



Turning 65 shouldn’t change your lifeNow that you’re eligible for Medicare, you have new options for health care coverage. MyBlue MedigapSM offers comprehensive coverage that’s convenient and helps protect you from the high cost of health care.

What is Medigap coverage?Medigap coverage, also called Medicare supplemental coverage, is a health plan that works in conjunction with Original Medicare to expand your Part A (hospital) and Part B (medical) benefits and lower your out-of-pocket costs. As your primary health coverage, Original Medicare provides comprehensive hospital and medical coverage, but it doesn’t cover all health care costs and has deductibles and coinsurance that must be paid before Medicare pays benefits. Medicare also limits coverage for certain services.

Medigap plans fill in the “gaps” in Original Medicare coverage. It expands or eliminates coverage limits and, depending on the plan you select, covers all or a portion of your Medicare deductibles and coinsurances. Blue Care Network of Michigan (BCN) offers MyBlue Medigap options for Plans A, C or F only. Other Michigan insurance carriers may offer other or additional plans, but Medigap plans can be sold in only 12 standard plans plus two high deductible plans (Plans A through J, and K and L). Every insurer must make Plan A available. Plan A covers basic benefits:

Hospitalization:• Part A coinsurance plus coverage for 365 additional days after Medicare benefits endMedical expenses:• Part B coinsurance (20 percent of Medicare-approved expenses) or copayments for hospital outpatient servicesBlood:• First three pints of blood each year

BASIC BENEFITS: For Plans A – J

PLAN A B C D E F/F* G H I J/J*

Basic Benefits x x x x x x x x x xSkilled Nursing coinsurance

x x x x x x x x

Part A Deductible x x x x x x x x xPart B Deductible x x xPart B Excess 100% 80% 100% 100%Foreign Travel Emergency

x x x x x x x x

At-Home Recovery x x x xPreventive Care not covered by Medicare

Blue Care Network offers Medigap options for Plans A, C and F. The overview of other plans is included for your information.


Basic Benefits for Plans K and L include similar services as plans A-J, but cost-sharing for the basic benefits is at different levels.

PLAN K** L**

Basic Benefits 100% of Part A hospitalization coinsurance plus coverage for 365 days after Medicare benefits end

50% Hospice cost-sharing

50% of Medicare-eligible expenses for the first three pints of blood

50% Part B coinsurance, except 100% coinsurance for Part B preventive services

100% of Part A hospitalization coinsurance plus coverage for 365 days after Medicare benefits end

75% Hospice cost-sharing

75% of Medicare-eligible expenses for the first three pints of blood

75% Part B coinsurance, except 100% coinsurance for Part B preventive services

Skilled nursing coinsurance

50% skilled nursing facility coinsurance

75% skilled nursing facility coinsurance

Part A Deductible 50% Part A deductible 75% Part A deductiblePart B DeductiblePart B Excess (100%)Foreign Travel EmergencyAt-Home RecoveryPreventive Care not covered by Medicare

$4,000 out of pocket Annual Limit*** $2,000 out of pocket Annual Limit***

* Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year ($1,790) deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses exceed ($1,790). 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 not include the plan’s separate foreign travel emergency deductible.

** Plans K and L provide for different cost-sharing for items and services than Plans A-J.

Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges.

***The out-of-pocket annual limit will increase each year for inflation.

This document is the MyBlue Medigap outline of coverage and the details and exceptions of MyBlue Medigap follow.

Like Medicare, MyBlue Medigap coverage is accepted nationwide and the plan is easy to use. There are no provider networks or referrals: Just use any health care provider that accepts Medicare. Simply present your MyBlue Medigap ID card along with your red, white and blue Medicare health insurance card whenever you receive health care services. We’ll coordinate payment with Medicare and your health care providers. In most cases, you’ll never have to bother with claim filing or paperwork.


Premium informationFor MyBlue Medigap plans, certain factors may affect your monthly premium cost. We base your premium on the area you live in and your age, gender, height, weight, and whether you use tobacco. Please note: If you are submitting your application within six months after you first enrolled for benefits under Medicare Part B or during the guaranteed renewability period (Special Enrollment Period), your rate will not be affected by your weight, height, smoking status, health status, claims experience, receipt of health care or medical condition. In all cases, Blue Care Network will not reject your application based on your health status or your age.

Your premium is based on your current age and will change as you age; the change will be reflected each year on the date of renewal. We can only raise your premium if we raise the premium for all policies like yours in Michigan.

Coverage replacementBecause MyBlue Medigap expands Original Medicare benefits, you need only one Medigap plan. If you have other coverage, such as coverage through an employer-sponsored health plan or another Medigap plan, you should not cancel that coverage until you have actually received your new ID card and are sure you want to keep MyBlue Medigap coverage.

Choose a plan option that meets your needs.This chart outlines the three coverage options offered by Blue Care Network: Plans A, C and F. Use the following chart and the premium charts on pages 3 – 14 to compare benefits and premiums among policies, certificates of coverage and contracts and premiums offered by BCN and other plans. The outline of coverage does not give all the details of Medicare coverage. For information about your Medicare Part A and Part B coverage, contact your local Social Security office or consult Medicare & You (online at medicare.gov/Publications). Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare which can be found on the Web at medicare.gov/medigap.

Note: The MyBlue Medigap plan may not fully cover all of your medical costs. When you receive covered services from a provider that does not accept Medicare assignment, you are responsible for the difference between the provider’s charge and the Medicare-approved amount, plus any deductible or coinsurance amounts required by the MyBlue Medigap plan you select.

Once enrolled in MyBlue Medigap, we’ll send you a member ID card and plan handbook that provides comprehensive details about your coverage. The certificate of coverage is your contract with BCN. The following is only an outline describing the most important features of BCN’s certificate of coverage. You must read the certificate to understand all of the rights and duties of both you and BCN. For more information about MyBlue Medigap coverage, call 877-4MY-BLUE (877-469-2583), or contact your Blue Care Network agent. TTY users should call 800-481-8704.

www.medicare.gov/Publications

www.medicare.gov/medigap


Covered servicePlan option Plan A Plan C Plan F

Medicare pays+ Plan pays You pay Plan pays You pay Plan pays You pay

Medicare Part A Hospital Coverage – includes semi-private room & board, general nursing care, miscellaneous services and supplies*

Deductible Nothing Nothing $1,100 $1,100 Nothing $1,100 Nothing

First 60 days of care 100% Nothing Nothing Nothing Nothing Nothing Nothing

Days 61 – 90 All but the $275 daily copayment $275 daily copay Nothing $275 daily copay Nothing $275 daily copay Nothing

Days 91 - 150 (Lifetime Reserve Days)

All but the $550 daily copayment $550 daily copay Nothing $550 daily copay Nothing $550 daily copay Nothing

Day 151 and beyond (additional 365 days after Lifetime Reserve Days used)

Nothing 100% of Medicare-eligible expenses Nothing 100% of Medicare-eligible

expenses Nothing 100% of Medicare-eligible expenses Nothing

Blood benefit* All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints Nothing

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 of care 100% Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Days 21–100 All but $137.50 daily skilled nursing facility copayment Nothing $137.50 daily copay $137.50 daily copay Nothing $137.50 daily copay Nothing

Hospice care

All but very limited coinsurance for outpatient

drugs and inpatient respite care

Nothing Balance Nothing Balance Nothing Balance

Emergency care outside the U.S.

No benefits for care outside U.S.

No benefits for care outside U.S. All costs for services

80% of approved amount for covered services,

after $250 deductible is met. Lifetime maximum

of $50,000

$250 deductible, plus 20% coinsurance



of $50,000


Medicare Part B Physician and Outpatient Services – In or out of the hospital and outpatient hospital physician’s diagnostic treatment, such as tests, durable medical equipment, per calendar year**

services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy,

Deductible (annual) Nothing Nothing $155 $155 Nothing $155 Nothing

Coinsurance80% of the approved

amount after $155 deductible is met

20% coinsurance after $155 deductible is met Nothing 20% coinsurance after

$135 deductible is met Nothing 20% coinsurance after $155 deductible is met Nothing

Blood benefit All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints NothingClinical laboratory services – tests for diagnostic services

All charges Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Home health care services – Medicare-approved servicesMedically necessary skilled care services and medical supplies


Durable medical equipment

80% of the approved amount after the $155

deductible is met

20% coinsurance after the $155 deductible is met Nothing 20% coinsurance after the

$155 deductible is met Nothing 20% coinsurance after the $155 deductible is met Nothing

Excess benefits Nothing Nothing All costs Nothing All costs All remaining charges *** Nothing

+ Based on 2010 Medicare premiums and deductibles.* Per benefit period. A benefit period begins on the first day you are hospitalized and ends after you have been out of the hospital and have not received skilled nursing care in any other facility for 60 consecutive days.** Note: the Part B deductible needs to be met only once each calendar year (Jan. 1 through Dec. 31).*** After Medicare makes payment up to the Limiting Charge established by law, and shown on your Medicare Explanation of Benefits.

Outline of coverage


Covered servicePlan option Plan A Plan C Plan F

Medicare pays+ Plan pays You pay Plan pays You pay Plan pays You pay

Medicare Part A Hospital Coverage – includes semi-private room & board, general nursing care, miscellaneous services and supplies*

Deductible Nothing Nothing $1,100 $1,100 Nothing $1,100 Nothing

First 60 days of care 100% Nothing Nothing Nothing Nothing Nothing Nothing

Days 61 – 90 All but the $275 daily copayment $275 daily copay Nothing $275 daily copay Nothing $275 daily copay Nothing

Days 91 - 150 (Lifetime Reserve Days)

All but the $550 daily copayment $550 daily copay Nothing $550 daily copay Nothing $550 daily copay Nothing

Day 151 and beyond (additional 365 days after Lifetime Reserve Days used)

Nothing 100% of Medicare-eligible expenses Nothing 100% of Medicare-eligible

expenses Nothing 100% of Medicare-eligible expenses Nothing

Blood benefit* All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints Nothing

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 of care 100% Nothing (Medicare covers in full) Nothing (Medicare covers in full) Nothing (Medicare covers in full)

Days 21–100 All but $137.50 daily skilled nursing facility copayment Nothing $137.50 daily copay $137.50 daily copay Nothing $137.50 daily copay Nothing

Hospice care

All but very limited coinsurance for outpatient

drugs and inpatient respite care

Nothing Balance Nothing Balance Nothing Balance

Emergency care outside the U.S.

No benefits for care outside U.S.

No benefits for care outside U.S. All costs for services



of $50,000




of $50,000


Medicare Part B Physician and Outpatient Services – In or out of the hospital and outpatient hospital physician’s diagnostic treatment, such as tests, durable medical equipment, per calendar year**

services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy,

Deductible (annual) Nothing Nothing $155 $155 Nothing $155 Nothing

Coinsurance80% of the approved

amount after $155 deductible is met

20% coinsurance after $155 deductible is met Nothing 20% coinsurance after

$135 deductible is met Nothing 20% coinsurance after $155 deductible is met Nothing

Blood benefit All but the first three pints Your first three pints Nothing Your first three pints Nothing Your first three pints NothingClinical laboratory services – tests for diagnostic services


Home health care services – Medicare-approved servicesMedically necessary skilled care services and medical supplies


Durable medical equipment

80% of the approved amount after the $155

deductible is met

20% coinsurance after the $155 deductible is met Nothing 20% coinsurance after the

$155 deductible is met Nothing 20% coinsurance after the $155 deductible is met Nothing

Excess benefits Nothing Nothing All costs Nothing All costs All remaining charges *** Nothing

+ Based on 2010 Medicare premiums and deductibles.* Per benefit period. A benefit period begins on the first day you are hospitalized and ends after you have been out of the hospital and have not received skilled nursing care in any other facility for 60 consecutive days.** Note: the Part B deductible needs to be met only once each calendar year (Jan. 1 through Dec. 31).*** After Medicare makes payment up to the Limiting Charge established by law, and shown on your Medicare Explanation of Benefits.


Eligibility for coverageAnyone who has Medicare Part A and Part B, lives in Blue Care Network’s service area for at least six months of the year and has a Michigan driver’s license or State ID card is eligible to enroll in MyBlue Medigap. A map of the BCN service area is on the inside back cover. You become eligible for MyBlue Medigap coverage at age 65 or the date you first enroll for Medicare Part B, whichever is later.

Enrolling in MyBlue Medigap is easyYou can apply for coverage on the Web at MiBCN.com, or contact your Blue Care Network agent. You can also complete the application in this brochure and mail it to:

Mail Code C411 Blue Care Network of Michigan P.O. Box 5043 Southfield, MI 48086-5043

Use one application for each person. Do not send payment with this application. We will send you an invoice for your first payment.

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

Please note: Whether you are applying for coverage on the Web or through a Blue Care Network agent, it is important to know that neither Blue Care Network nor its agents are connected with Medicare.

If you’re currently covered by a Blue Cross Blue Shield of Michigan, Blue Care Network of Michigan or BCN Service Company group plan, please call 877-4MY-BLUE or contact your Blue Care Network insurance agent for information on how to enroll in the MyBlue Medigap plan. Indicate that you’re switching to a Medigap plan from your current coverage. We’ll help you enroll and ensure that you have no lapse in coverage.

If you’re covered under a health policy from any other insurer, do not cancel that coverage until you receive your MyBlue Medigap certificate and are sure you want to keep it. We will mail a booklet to you that includes your certificate when we enroll you in the plan.

If you have questions, please call 877-4MY-BLUE (469-2583) or contact your Blue Care Network insurance agent. TTY users should call 800-481-8704.

Changing your coverageYou may switch to a different Medigap policy once per year on the date you originally enrolled in MyBlue Medigap.

You may cancel this coverage if it’s not right for you If you find that you are not satisfied with BCN MyBlue Medigap coverage, notify us by phone or write to us at the address below. If you send your MyBlue Medigap ID card back to us within 30 days after you receive it, we will treat the coverage as if it had never been issued and return all of your payments, less the reasonable cost of any health services paid by BCN during that time. You will be responsible for any deductibles or coinsurance for Medicare Part A and Part B claims or any services not covered by Original Medicare incurred during that 30-day period.

Mail Code C411 Blue Care Network of Michigan P.O. Box 5043 Southfield, MI 48086-5043

Do you also need prescription drug coverage?You may also purchase Medicare Part D drug coverage with Blue Cross Blue Shield of Michigan’s Prescription BlueSM PDP plan.

Complete answers are very importantWhen you fill out the application for the BCN MyBlue Medigap coverage, be sure to answer truthfully and completely all questions about your medical and health history. BCN 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.

www.MiBCN.com


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115

120

126

131

136

142

147

153

158

164

169

175

180

186

191

196

202

207

213

218

5’3”

8587

9610

210

711

311

812

413

013

514

114

615

215

816

316

917

518

018

619

119

720

320

821

422

022

5

5’4”

8790

9910

511

011

612

212

813

414

014

515

115

716

316

917

418

018

619

219

720

420

921

522

122

723

2

5’5”

9093

102

108

114

120

126

132

138

144

150

156

162

168

174

180

186

192

198

204

210

216

222

228

234

240

5’6”

9396

105

112

118

124

130

136

142

148

155

161

167

173

179

186

192

198

204

210

216

223

229

235

241

247

5’7”

9699

109

115

121

127

134

140

146

153

159

166

172

178

185

191

198

204

211

217

223

230

236

242

249

255

5’8”

9910

211

211

812

513

113

814

415

115

816

417

117

718

419

019

720

321

021

622

323

023

624

324

925

626

2

5’9”

102

105

115

122

128

135

142

149

155

162

169

176

182

189

196

203

209

216

223

230

236

243

250

257

263

270

5’10

”10

510

811

812

513

213

914

615

316

016

717

418

118

819

520

220

921

622

222

923

624

325

025

726

427

127

8

5’11

”10

811

212

212

913

614

315

015

716

517

217

918

619

320

020

821

522

222

923

624

325

025

726

527

227

928

6

6’ 0

”11

111

512

513

314

014

715

416

216

917

718

419

119

920

621

322

122

823

524

225

025

826

527

227

928

729

4

6’ 1

”11

411

812

913

614

415

115

916

617

418

218

919

720

421

221

922

723

524

225

025

726

527

228

028

829

530

2

6’ 2

”11

712

113

214

014

815

516

317

117

918

619

420

221

021

822

523

324

124

925

626

427

228

028

729

530

331

1

6’ 3

”12

012

513

614

415

216

016

817

618

419

220

020

821

622

423

224

024

825

626

427

227

928

729

530

331

131

9

6’ 4

”12

312

814

014

815

616

417

218

018

919

720

521

322

123

023

824

625

426

327

127

928

729

530

431

232

032

8


Notes:


Notes:


Notes:


BCN service area map

BCN is only available in portions of this county

BCN is not available in these counties

Greater Michigan region*

Southeast region**

BCN is only available in portions of these counties

Alcona

Allegan

AlpenaAntrim

Arenac

Barry

Bay

Benzie

Berrien Branch

Calhoun

Cass

Charlevoix

Cheboygan

Clinton

Crawford

Eaton

Emmet

Genesee

Gladwin

GrandTraverse

Gratiot

Hillsdale

Huron

Ingham

Ionia

Iosco

Isabella

JacksonKalamazoo

Kalkaska

Kent

Lake

Lapeer

Leelanau

Lenawee

Livingston

Mackinac

Macomb

Manistee

Mason

Mecosta Midland

Missaukee

Monroe

Montcalm

Mont-morency

Muskegon

Newaygo

Oakland

Oceana

Ogemaw

Osceola

Oscoda

Otsego

Ottawa

Presque Isle

Ros-common

Saginaw

St. Clair

St. Joseph

Sanilac

Shia-wassee

Tuscola

Van BurenWashtenaw Wayne

Wexford

Clare

34 MyBlue Medigap — Plans A, C and F092459INDBCB 10833 AUG 09

bcbsm.com/mybluemedicare

To enroll:

See your Blue Care Network agent•

Enroll online at • MiBCN.com

Call 877-469-2583 •TTY users call 800-481-8704

www.bcbsm.com/mybluemedicare

www.MiBCN.com

Documents

Medicare Supplement Coverage offered by MyBlue Medigap · 2009-10-27 · If your BMI is You’re in Tier 15 or 16 2 17 to 30 1 31 to 35 2 36 to 40 3 If your BMI is not on the BMI