Senior SecurityBenefit Plan Booklet – Plan F

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D16804 06/10 16804 0610

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SS Plan F 06/10 1

SENIOR SECURITY – BENEFIT PLAN F Dear Medicare Supplement Customer: We want to welcome you as a Senior Security customer of Blue Cross Blue Shield of Arizona (BCBSAZ). Your Senior Security policy provides benefits for residents of Arizona who are age 65* or older and who are enrolled in Medicare Parts A and B. Renewal provision: Once you have enrolled, your initial coverage under this policy will continue as long as you pay your premiums. BCBSAZ reserves the right to change the premium, subject to a 30-day notice, provided like action is taken on all similar Senior Security policies. If you are not satisfied with this policy for any reason, you may cancel it by notifying BCBSAZ in writing within 30 days after you receive it. If you cancel the policy within this 30-day period, BCBSAZ will refund any premium you have paid and rescind the policy as though it was never in effect. We thank you for your participation and look forward to serving you. Richard L. Boals, President and CEO Blue Cross Blue Shield of Arizona, Inc. Notice to Buyer: This policy may not cover all your medical expenses. *Depending on your birthday, you may be eligible during the time period when you are enrolled in Medicare Parts A and B and you are 64 if you are in your 65th birthday month or you turn 65 the first day of the month following your Medicare Part B coverage.

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TABLE OF CONTENTS

CUSTOMER SERVICE INFORMATION......................................................................... 4

DEFINITIONS ................................................................................................................. 6

UNDERSTANDING THE BASICS................................................................................... 9 Senior Security Overview ..................................................................................... 9 Your Responsibilities ............................................................................................ 9 BCBSAZ ID Card.................................................................................................. 9 Benefit Maximums ................................................................................................ 9 Coverage Changes............................................................................................. 10 Covered Services ............................................................................................... 10 Medically Necessary........................................................................................... 10 Outline of Coverage............................................................................................ 10

DESCRIPTION OF BENEFITS ..................................................................................... 11 Medicare Part A.................................................................................................. 11

Inpatient Services .................................................................................... 11 Skilled Nursing Facility............................................................................. 12 Blood ...................................................................................................... 12 Hospice.................................................................................................... 12

Medicare Part B.................................................................................................. 13

Physician Services and other Medical Expenses..................................... 13 Outpatient Services ................................................................................. 13 Clinical Laboratory Services—Tests for Diagnostic Services................... 14 Blood ...................................................................................................... 14

Medicare Parts A & B ......................................................................................... 14

Home Health Care ................................................................................... 14 Other Benefits Not Covered By Medicare........................................................... 14

Foreign Travel Emergency....................................................................... 14

EXCLUSIONS – WHAT IS NOT COVERED ................................................................. 16

CLAIMS INFORMATION............................................................................................... 18 Provider Submission of Claims........................................................................... 18 Issuance of Payment .......................................................................................... 18 Providers Outside the United States................................................................... 18

ENROLLMENT INFORMATION.................................................................................... 19 When Coverage Starts ....................................................................................... 19 Renewal Provision.............................................................................................. 19 Who Is Covered.................................................................................................. 19 Termination of Coverage .................................................................................... 19 Coverage After Termination ............................................................................... 19 Suspension Of Coverage ................................................................................... 20 Rescission Of Contract....................................................................................... 20 Replacing Your Policy ........................................................................................ 20

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Your Premium..................................................................................................... 21 Billing Options.......................................................................................... 21 Grace Period............................................................................................ 21

Premium Change Notification ............................................................................. 21

GRIEVANCE PROCEDURE/REQUEST FOR RECONSIDERATION........................... 22

CONDITIONS, LIMITATIONS AND GENERAL INFORMATION................................... 23 Blue Cross and Blue Shield Association............................................................. 23 Broker Commissions .......................................................................................... 23 Confidentiality and Release of Information ......................................................... 23 Legal Action and Applicable Law........................................................................ 23 Member Notices and Communications............................................................... 24 Non-Assignability of Benefits .............................................................................. 24 Outstanding Checks ........................................................................................... 24 Payments Made in Error..................................................................................... 24 Provider Treatment Decisions and Disclaimer of Liability................................... 25 Release of Records ............................................................................................ 25 Time Limit On Claims; Notice Of Claim .............................................................. 25 Third-Party Beneficiaries .................................................................................... 25 Your Right to Information.................................................................................... 25

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CUSTOMER SERVICE INFORMATION You need to understand your health insurance benefits and the limitations on those benefits before you receive services. If you have any questions, please contact BCBSAZ at one of the departments listed below or call the direct phone number on the back of your ID card. BCBSAZ also makes information available at www.azblue.com and you may wish to look there before calling. BlueNet is the member area on www.azblue.com that allows you to manage your health insurance policy from anywhere you have Internet access. Go to www.azblue.com/member for more information and to register for a BlueNet account. Once you are registered for BlueNet, you have access to the following*: Claims and benefits information Update account information Compare hospitals Verify enrollment status HealthyBlue® - tools for a healthier lifeOrder ID cards *Depending on your policy, access to links on BlueNet may vary. BCBSAZ Customer Service hours: Monday through Friday,

8:00 a.m. to 4:30p.m.MST (except Holidays)

Customer Service (benefit questions or claim information)

Phoenix Statewide

(602) 864-4122 (800) 232-2345 Ext. 4122

Hearing Impaired (TDD) (claim information)

Phoenix

(602) 864-4823

Spanish Language Telephone Service (en Español – preguntas, sobre su aplicación, beneficios, reclamos o pagos)

Phoenix Statewide

(602) 864-4884 (800) 232-2345 Ext. 4884

Membership Services (billing or premium information, change mail address, termination of coverage)

Maricopa County Statewide Fax

(602) 864-4115 (800) 232-2345, ext. 4115 (602) 864-4041

Attn: Membership Services Mail Stop: A102 Blue Cross Blue Shield of Arizona PO Box 13466 Phoenix, AZ 85002-3466

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Supply Line (replacement ID cards, claim forms, grievance information packet)

Phoenix Statewide

(602) 995-6960 (800) 232-2345 Ext. 6960

Healthline (free health education brochures)

Online at Phoenix Statewide

www.azblue.com(602) 864-4625 (800) 232-2345 Ext. 4625

HealthyBlue Discounts

Online at

www.azblue.com/discounts

MAIL CLAIMS AND CORRESPONDENCE TO:

Blue Cross Blue Shield of Arizona P.O. Box 13466 Phoenix, Arizona 85002-3466

Customer Walk-In Office Locations

Phoenix (main office) 2444 W. Las Palmaritas Drive, 85021-4883 (2 blocks north of Northern Avenue between the Black Canyon Freeway (I-17) and 23rd Avenue)

Tucson 5285 E. Williams Circle, Suite 1000, 85711- 7411 (East on Broadway Road, right on S. Williams Circle, left on E. Williams Circle)

Flagstaff 1500 E. Cedar Avenue, Suite 56, 86004 -1643 (Intersection of Cedar Avenue and West Street)

Tempe 4415 S. Wendler Drive, Suite 100, 85282-6411

(I-10 to Baseline Road, exit west to Wendler Drive, south to end of street)

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DEFINITIONS

“Ambulatory surgical facility” means a facility licensed as an outpatient surgical center by the Arizona Department of Health Services, or the appropriate state licensing agency if outside Arizona, and that is Medicare certified. “BCBSAZ” or “We” means Blue Cross Blue Shield of Arizona, the issuer of this Medicare Supplement insurance policy. Blue Cross® Blue Shield® of Arizona is an independent licensee of the Blue Cross and Blue Shield Association. BCBSAZ is a non-profit corporation organized under the laws of the State of Arizona as a hospital, medical, dental and optometric service corporation. “Benefit book” means this document, which may also be referred to as benefit booklet or policy booklet. "Benefit plan" or “plan” means the standardized benefit options defined by state and federal law that may be offered as Medicare supplement policies. These plans are identified by letter, e.g., A, B, C, etc. “Benefit period” means the period of time that begins on the first day you are an inpatient in either a hospital or a skilled nursing facility and ends 60 days after the last day you are an inpatient in either a hospital or skilled nursing facility. “BlueNet” means a section of www.azblue.com, the BCBSAZ web site, that offers member services including online enrollment, data management tools, customizable access options and online support. “Condition” means any disease, illness, ailment, injury or bodily malfunction of a policy holder that is eligible for Medicare benefits. “Copay” means a fixed fee paid by the policy holder to a provider at the time of service. “Effective Date” means the date the policy holder’s coverage begins. “Emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: • Serious jeopardy to the health of the individual; • Serious impairment to bodily functions; or • Serious dysfunction of any bodily organ or part. “Facility” means a hospital, nursing care institution, ambulatory surgical facility, urgent care facility, or home health agency that is licensed by the Arizona Department of Health Services, or the appropriate state licensing agency if outside Arizona, and, with the exception of an urgent care facility, is Medicare certified.

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“Home Health Agency” means a Medicare certified agency that provides intermittent skilled nursing and rehabilitation services in the home and is licensed by the Arizona Department of Health Services, or the appropriate state licensing agency if outside Arizona. “Hospice” means a public agency or private organization that is Medicare certified as a hospice and provides pain relief, symptom management and supportive services to terminally ill persons and their families. “Hospital” means a facility primarily engaged in providing medical care and treatment of ill and injured persons. Medical, diagnostic and major surgical services must be provided on the premises or arrangements for such services must be made with a licensed facility. These services must be provided under the supervision of a staff of physicians with 24-hour per day nursing service. The hospital must be licensed as a general hospital, special hospital or behavioral health institution by the Arizona Department of Health Services, or the appropriate state licensing agency if outside Arizona, and Medicare certified. “Inpatient” means the person covered under this policy who is admitted for a medically necessary stay in a hospital or skilled nursing facility for at least one full night and for whom a room and board charge is properly made. “Lifetime reserve days” means a maximum total of 60 lifetime reserve days of inpatient hospital services that Medicare beneficiaries may use after being hospitalized for more than 90 days in a benefit period. Medicare pays for all covered services received during lifetime reserve days, except for a daily coinsurance amount. “Limiting charge” means the highest amount, as determined by Medicare, that you can be charged for certain covered services by providers who do not accept Medicare assignment. The limiting charge is 15 percent more than the Medicare approved amount, applies only to certain services, and does not apply to supplies or equipment. “Medicare” means the federal government health insurance program established by Title XVIII of the Social Security Act. Original Medicare means the health insurance available under Medicare Part A and Part B through traditional fee-for-service coverage. “Medicare-approved amount” means the charge for a Medicare- eligible expense that Medicare determines is appropriate. This amount may be lower than the actual amount charged by a provider or supplier. Payment by Medicare and BCBSAZ under this policy is based on the Medicare-approved amount unless otherwise specifically stated in this policy. “Medicare certified” means a facility or hospice that has met the standards required by Medicare and has received a letter of acceptance from Medicare. “Medicare coinsurance” means the portion, if any, of the Medicare- approved amount that you must pay in addition to the Medicare deductible. “Medicare deductible” means the initial dollar amount, if any, that must be paid before Medicare begins to pay its share of the Medicare-approved amount. “Medicare-eligible expense” means expenses of the kinds covered by Medicare Parts A and B, to the extent recognized as reasonable and medically necessary by Medicare.

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"Member" or "You" means an individual covered under this policy. “Outline of coverage” means the separate booklet that you received when you applied and which is available upon request; it is part of the policy, lists the covered amounts, Medicare coinsurance and Medicare deductible, and contains other important customer information. “Outpatient” means services provided on other than an inpatient basis. “Physician” means any licensed doctor of medicine (M.D.), doctor of osteopathy (D.O.), doctor of podiatry (D.P.M.), doctor of dental surgery (D.D.S.), doctor of medical dentistry (D.M.D.), doctor of chiropractic (D.C.), or doctor of optometry (O.D.) or other licensed physicians defined by Medicare. "Policy" (sometimes referred to as “Agreement”) means and includes your application for coverage, the outline of coverage, this benefit book, your ID card, any benefit book that is issued to replace this benefit book, and any rider, amendment or modification to this benefit book. "Policy holder" means the individual who signs the application for coverage and in whose name the policy is issued. “Provider” means physicians or facilities, as defined in this policy, licensed where required, and performing services within the scope of their license. "Service" means a generic term referencing some type of health care treatment, test, procedure, supply, medication, technology, device or equipment. “Skilled nursing facility” means a nursing care institution primarily engaged in providing skilled nursing care or rehabilitation services that is licensed as a nursing care institution by the Arizona Department of Health Services, or the appropriate state licensing agency if outside Arizona, and Medicare certified. “Urgent care facility” means a facility licensed as an outpatient treatment center by the Arizona Department of Health Services, or the appropriate state licensing agency if outside Arizona.

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UNDERSTANDING THE BASICS Senior Security Overview This policy provides Medicare Supplement health care coverage through Blue Cross Blue Shield of Arizona (“BCBSAZ”). You may receive covered services from any provider who is properly licensed, certified or registered in accordance with applicable state law and Medicare requirements. This policy does not require you to receive covered services from a provider that is contracted with BCBSAZ in order for you to be eligible for benefits. Your Responsibilities Read your benefit materials. Before you receive any services you need to understand what is covered and excluded under your policy, your cost-sharing obligations and the steps you can take to minimize your out-of-pocket costs. You need to carefully review this book, your outline of coverage and other materials that BCBSAZ has provided to you. Tell us about changes. We need current information to correctly process your claims, update you on changes to your benefits and explain how we are administering your policy. Check the customer service section at the front of this book for information on contacting Membership Services. Tell us right away about any changes in the following: • Your mailing address, phone number, or email address (if you have given it to us) • Other medical coverage that you add or lose, including any changes in benefits • Your eligibility for Arizona Health Care Cost Containment System (AHCCCS) coverage

during the term of this contract If you do not tell us about changes, correspondence from BCBSAZ may not reach you in a timely manner. Also, you may have to reimburse BCBSAZ for claims payments we make on your behalf, if you became ineligible but incurred claims before you gave us notice. You may also have to pay costs incurred by BCBSAZ for collection of claims payments made after you became ineligible. BCBSAZ ID Card BCBSAZ issues you an identification card. Your ID card has basic eligibility and cost-sharing information: Member name, group number, ID number, card issue date and certain cost-sharing amounts. • Bring your ID card with you each time you seek health care services. • Have your ID card available for reference when you contact BCBSAZ for information. If you lose your card and need a temporary copy, you can print a copy from our web site at www.azblue.com after you have signed up for a Blue Net account on the web site. Benefit Maximums Some benefits may have a specific benefit maximum. Benefits may have a maximum limit based on dollar amount, number of days or visits, type, timeframe (annual, calendar year or lifetime), or other factors. If you reach a benefit maximum, any further services are not covered and the provider can bill you full billed charges for those services.

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All benefit maximums are included in the applicable benefit description. Coverage Changes BCBSAZ reserves the right to make changes in your benefits and coverage under this policy, as permitted by state and federal law. Amounts payable under this policy generally change to match Medicare’s benefit and coverage changes. We will notify you of any changes at least 30 days in advance, or as otherwise required by law. If your benefits change, those changes will apply uniformly to all persons covered under this Plan, and only to covered services provided on or after the effective date of the change. If Medicare benefits change, your coverage will be updated to reflect these changes, and you will be notified of any resulting premium change. Covered Services To be covered a service must be all of the following: • Classified by Medicare as an eligible expense or otherwise approved by BCBSAZ; • Stated benefits of the policy; • Not excluded from coverage; and • Prescribed or performed by providers acting within their scope of practice. Medically Necessary BCBSAZ will accept Medicare’s determination of medical necessity when benefits under this policy are provided for services which are Medicare-eligible expenses. When this policy provides benefits for foreign travel emergency services, BCBSAZ will determine medical necessity. Determinations about medical necessity may differ from your provider’s opinion. A provider may prescribe, order, recommend or approve a service that Medicare or BCBSAZ decides is not medically necessary and therefore is not a covered benefit. You and your provider should decide whether to proceed with a service that is not covered. In addition, not all medically necessary services will be covered benefits under this policy. All policies have exclusions and limitations on what is covered. A service may be medically necessary and still excluded from coverage. Outline of Coverage BCBSAZ gives you an outline of coverage that summarizes your benefits, cost-sharing amounts, and other important information. Please keep your current outline of coverage with your benefit book.

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DESCRIPTION OF BENEFITS There are two parts to the Original Medicare program. Part A hospital insurance helps pay for inpatient hospital care, inpatient care in a skilled nursing facility, home health and hospice care. Part B helps pay for doctors’ services, outpatient services, durable medical equipment and other medical services and supplies. Your Senior Security benefits are designed to supplement Medicare by covering limited hospital, medical and surgical services which are partially covered by Medicare. This book and your outline of coverage describe the benefits of the Senior Security policy you have chosen. Please review them carefully. This Medicare Supplement Benefit Plan F covers only the following benefits as supplemental coverage to your Medicare Part A and Part B coverage. Medicare Part A Inpatient Services

For a Medicare-eligible hospital stay, this policy will provide the following supplemental coverage to Medicare Part A:

• Days 1-60: In the first 60 days of a benefit period, Medicare pays all but your deductible

amount for an eligible inpatient hospital stay. This policy pays the Medicare Part A deductible.

• Days 61-90: From the 61st day through the 90th day of the same benefit period,

Medicare pays all but the coinsurance for an eligible inpatient hospital stay. This policy pays the Medicare Part A coinsurance.

Medicare Lifetime Reserve Days: Medicare will also pay all but the coinsurance for an additional 60 days of an inpatient hospital stay. These days are called “lifetime reserve days” because they can be used when needed until your Medicare coverage terminates. You can use a lifetime reserve day only once. After you use all of your lifetime reserve days, they are gone and cannot be used again during your lifetime. This policy pays the Medicare Part A coinsurance for “lifetime reserve days.”

Inpatient Psychiatric Services: Medicare will pay for inpatient psychiatric hospital stays on the same basis as for other inpatient hospital stays. However, Medicare will not pay for more than 190 days of inpatient services in a specialty inpatient psychiatric hospital during the patient’s lifetime. The 190-day limitation does not apply to inpatient mental health services received in a psychiatric unit of an acute care hospital or critical access hospital. Additional 365 Days: After you have used all of your Part A Medicare hospital benefits, this policy will cover Medicare Part A eligible expenses for an additional 365 days of inpatient hospital care. Payment will be made at the rate Medicare would have paid or other appropriate standard of payment negotiated by BCBSAZ, subject to a lifetime maximum benefit of an additional 365 days. Once you have used all of your Additional 365 Days, they are gone. You cannot use them again during your lifetime.

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Skilled Nursing Facility

First 20 Days: Medicare provides the first 20 days of medically necessary skilled nursing facility care in a benefit period at no cost to you if you meet all of the following requirements:

• You have not used all of your skilled nursing days in your Part A benefit period

(Medicare covers no more than 100 days of skilled nursing care during a single benefit period);

• You are admitted to a skilled nursing facility within a short time (usually 30 days) of your

discharge from a hospital; • Your hospital stay was of at least three days duration; and • Your physician determines that you need the skilled nursing care. Days 21-100: From the 21st day through the 100th day of the same benefit period, Medicare will pay for all Medicare-eligible expenses except the coinsurance. This policy pays the Medicare Part A coinsurance for days 21 through 100. After 100 Days: This policy does not provide skilled nursing facility benefits after the 100th day of care in the same benefit period.

Blood

Medicare Part A has a calendar year deductible equal to the cost of the first three pints of blood or equivalent quantities of packed red blood cells, unless the blood is donated by you or someone else, or otherwise provided at no cost by a blood bank. Each calendar year, this policy will pay for the first three pints of blood or equivalent quantities of packed red blood cells you receive while in an inpatient hospital, provided the blood is not donated by you or someone else, or otherwise provided at no cost by a blood bank. Medicare pays 100% of the cost for any additional blood for that calendar year. To the extent that the blood deductible is met under Part B, it does not have to be met under the Part A deductible.

Hospice

Medicare pays all costs for hospice care except for limited copays or coinsurance for outpatient drugs and inpatient respite care if you meet all of the following requirements:

• Your physician certifies that you have a terminal illness; and • You elect palliative care instead of treatment for your illness. This policy pays all Medicare copays and coinsurance for hospice care and inpatient respite care.

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Medicare Part B Medicare does not begin to pay Part B benefits until you have paid a fixed dollar amount each calendar year. This amount is your Medicare Part B deductible. This policy pays your Part B deductible. After the Medicare Part B calendar year deductible is satisfied, Medicare generally pays 80% of the Medicare approved amount for all Medicare eligible expenses (except the first three pints of blood) covered under Part B of its plan. In some cases, Medicare may pay more or less than 80% of the Medicare-approved amount. If this policy is responsible for the Medicare coinsurance or copayment, this policy will pay the full amount of the coinsurance or copayment, even if such amount is more or less than 20% of the Medicare-approved amount. Medicare decides what the Medicare-approved amount will be for Medicare-eligible expenses under Part B. A provider who accepts Medicare assignment agrees to accept the Medicare approved amount. A provider who does not accept Medicare assignment may bill you more than the Medicare-approved amount. The amount that the provider is allowed to collect is limited by law. This policy pays the difference between the Medicare-approved amount and the provider’s billed charge, up to the amount the provider is lawfully allowed to collect for Medicare eligible expenses. This amount is called Part B excess charges. This policy covers, in part, the following services and supplies: Physician Services and other Medical Expenses After the Part B calendar year deductible is satisfied, Medicare generally pays 80% of the Medicare-approved amount for Medicare-eligible services including physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests and durable medical equipment. This policy will pay the remainder of the Medicare- approved amount. If the provider does not accept Medicare assignment, this policy also will pay 100% of the Part B excess charges, up to the amount the provider is lawfully allowed to collect. Outpatient Services

Medicare will pay 80% of the Medicare-approved amount for Medicare eligible expenses such as laboratory and X-ray tests, medical supplies, diagnostic tests and monitoring services, rehabilitation therapies, ambulance, and drugs or biologicals which cannot be self-administered. This policy will pay the remaining 20% of the Medicare- approved amount. If the provider does not accept Medicare assignment, this policy also will pay 100% of the Part B excess charges, up to the amount the provider is lawfully allowed to collect.

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Clinical Laboratory Services—Tests for Diagnostic Services

Medicare will pay 100% of the Medicare-approved amount for Medicare eligible expenses for clinical laboratory services and tests for diagnostic services.

Blood Medicare Part B has an additional calendar year deductible equal to the cost of the first 3 pints of blood or equivalent quantities of packed red blood cells, unless the blood is donated by you or someone else, or otherwise provided at no cost by a blood bank. Each calendar year, this policy provides benefits to pay for the first three pints of blood or equivalent quantities of packed red blood cells you receive as an outpatient, provided the blood is not donated by you or someone else, or otherwise provided at no cost by a blood bank. To the extent that the blood deductible is met under Medicare Part A during the calendar year, it does not have to be met under Part B.

Following the first three pints and after your Medicare Part B deductible is met, Medicare pays 80% of the Medicare approved amount for additional pints of blood. This policy pays the Medicare Part B deductible and 20% of the Medicare-approved amount for additional pints of blood.

Medicare Parts A & B

Home Health Care Medicare pays 100% of the Medicare-approved amount for medically necessary skilled care services and medical supplies (other than durable medical equipment) provided through home health care under the following conditions:

• Your physician determines that you need home health care; • You need intermittent skilled nursing care (other than just drawing blood), physical

therapy, speech-language pathology services, or continued occupational therapy; • Your home health agency is Medicare-certified; and • You are unable to leave your home without assistance.

Medicare pays 80% of the Medicare-approved amount after your Part B calendar year deductible is met for durable medical equipment prescribed for use in your home. This policy will pay the remaining 20% of the Medicare- approved amount for such services.

Other Benefits Not Covered By Medicare Foreign Travel Emergency Medicare generally does not pay for services received outside the United States. After you satisfy a $250 calendar year deductible, this policy will pay 80% of billed charges for Medicare eligible expenses, up to a lifetime maximum of $50,000 for medically necessary emergency care received outside of the United States under the following conditions:

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• You needed care immediately because of an injury or an illness of sudden and unexpected onset;

• The care begins within 60 days after you left the United States; and • The care would have been covered by Medicare if provided in the United States.

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EXCLUSIONS – WHAT IS NOT COVERED

This policy provides benefits only for services covered under Medicare Parts A and B, and for any additional benefits specifically listed in this policy. Services excluded from coverage under Medicare Parts A and B are subject to periodic change and may not be included in this list of exclusions. This policy will not pay any benefits that duplicate reimbursement paid through the Medicare program, or for expenses associated with: Activity therapy – Activity therapy and milieu therapy, including community immersion, integration, home independence and work re-entry therapy; and any care intended to assist an individual in the activities of daily living; and any care for comfort and convenience, except for limited hospice benefits Acupuncture Alternative therapies, as determined by Medicare Charges associated with the preparation, copying or production of health records Complications of noncovered services – Complications and consequences, whether immediate or delayed, arising from any condition or service not covered under this policy Cosmetic or aesthetic surgery, procedures, treatments and office visits and/or consultations and other services for cosmetic purposes. “Cosmetic” means surgery, procedures or treatment and other services performed primarily to enhance or improve appearance, even if such services will improve emotional, psychological or mental condition or function. However, benefits may be available for breast reconstruction if you had a mastectomy because of breast cancer, or for services needed because of accidental injury or to improve the function of a malformed part of the body, as allowed by Medicare. Custodial care Dental services or supplies, except for limited coverage under Medicare Part A Expenses for services that exceed benefit limitations Free services – Services you receive at no charge or for which you have no legal obligation to pay Hearing services and devices – Routine hearing exams and hearing aid services and supplies. Massage therapy Non-medically necessary services – Services that are not medically necessary as determined by Medicare or by BCBSAZ Orthopedic shoes or therapeutic shoes, except as determined by Medicare

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Personal comfort Items – Services intended primarily for assistance in daily living, socialization, personal comfort, convenience and other non-medical reasons Prescription drugs covered through Medicare Part D Routine eye care and most eyeglasses – except for one pair of standard frames after cataract surgery with an intraocular lens, as determined by Medicare Routine foot care, except for limited coverage as determined by Medicare Routine or yearly physical exams Services prior to effective date Services provided after the member’s coverage termination date, except as stated in this policy Services that have been delivered to you or for which you are eligible as a member of a Medicare Advantage plan Skilled nursing facility care of any kind beyond what is covered by Medicare Services provided to you while traveling outside of the United States and territories, except as stated in this policy

PRE-EXISTING CONDITION WAITING PERIODS

This plan does not have any pre-existing condition waiting periods at any time.

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CLAIMS INFORMATION Provider Submission of Claims Most providers, including hospitals, skilled nursing facilities and physicians, will file Medicare claims for you. Generally, when Medicare has processed the claim as primary payor, Medicare will automatically generate a secondary claim and send it electronically to BCBSAZ as the secondary payor. In most cases, Medicare forwards the claim to BCBSAZ, even if you received emergency or other covered services from providers outside Arizona. When Medicare adjudicates your primary claim, you will receive a Medicare Summary Notice (MSN) telling you which services were covered and any services that were disallowed. You should keep the notice for your personal records. When Medicare has forwarded the claim to BCBSAZ for secondary payment, you will also see the following message on your Medicare Summary Notice: “This information is being sent to BCBS.”

If this message does not appear on the Medicare Summary Notice, you may need to file a claim. Before doing so, you should first check with the treating provider to see if the provider has already submitted the secondary claim to BCBSAZ. If the provider has not submitted the claim, you must file the claim with BCBSAZ. You must send BCBSAZ the completed claim form, a copy of the itemized bill and the Medicare Summary Notice. Claim forms are available from any BCBSAZ office or by calling (602) 995-6960 or (800) 232-2345, ext. 6960. Issuance of Payment If an Arizona provider is contracted with BCBSAZ or an out-of-state Blue Plan, or is a noncontracted provider (in or outside of Arizona) who accepts Medicare assignment, BCBSAZ will pay the provider. BCBSAZ does issue payments directly to out-of-state providers who accept Medicare assignment, regardless of the provider’s contract status with the Blue plan in the state where you received services. If the provider is noncontracted and does not accept assignment, BCBSAZ will issue payment to you, and you must pay the provider. Providers Outside the United States You will probably have to pay for all outpatient and inpatient hospital care outside of the United States at the time of service. After you submit a claim to and receive a response from Medicare, you should then send a copy of the paid itemized bill and the Medicare Summary Notice to BlueCard Worldwide Service Center, P.O. Box 72017, Richmond, VA 23255-2017, along with a completed claim form. For assistance, call (804) 673-1177. If the services you received outside the United States are covered, payment will be made directly to you. When you call or write, be sure to give your BCBSAZ identification numbers from your ID card and your full name and address. If the question involves a claim, be sure to give the date of service, name of provider, the type of service you received, and the charges involved. If possible, please include a copy of the itemized statement and the Medicare Summary Notice when you write. Always make copies of your claim form and any statements for your records before filing a claim.

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ENROLLMENT INFORMATION When Coverage Starts To be eligible for this policy, in general a policy holder must be age 65 years* or older and enrolled in Medicare Parts A and B. Your coverage will begin on your effective date. This will be the first day of the month following BCBSAZ’s approval of your application. *Depending on your birthday, you may be eligible during the time period when you are enrolled in Medicare Parts A and B and you are 64 if you are in your 65th birthday month or you turn 65 the first day of the month following your Medicare Part B coverage. Renewal Provision Once you have enrolled, your coverage under this policy will continue as long as you pay your premiums. Who Is Covered Only you, the policy holder, are covered. Termination of Coverage This policy excludes payment of benefits for medical services incurred or received for any reason or condition after termination of the policy, except as specifically provided elsewhere in this policy.

Your coverage will terminate on the earliest of the following:

• Upon receipt by BCBSAZ of a written request made by the policy holder. Termination will be effective on the first day of the month following the date the request was received by BCBSAZ. A premium that had been prepaid 30 days or longer will be refunded to you.

• The date the premium was due, if the premium has not been received by BCBSAZ

within the 30-day grace period. Coverage After Termination If you are an inpatient in a hospital or skilled nursing facility at the time your policy terminates, coverage of Medicare eligible expenses will continue until the earlier of the following:

• The end of the benefit period in which the inpatient stay began; or • Payment of the maximum inpatient benefits under this policy.

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Suspension Of Coverage If you are entitled to medical assistance under Title XIX of the Social Security Act (AHCCCS in Arizona), you may suspend your coverage for a period not to exceed 24 months provided you notify BCBSAZ in writing within 90 days after the date of your entitlement. BCBSAZ will return to you any portion of unused premium subject to any adjustment for claims paid.

If you lose or terminate your entitlement to medical assistance as described above, you may be covered again under substantially equivalent BCBSAZ coverage effective the date of your termination provided:

• You notify BCBSAZ within 90 days after the date of your loss or termination of entitlement; and

• You pay all of the applicable premium from the date medical assistance terminated.

Your new premium will be the premium that you would have been charged had your coverage not been suspended. Upon reinstatement, you will not be subject to any waiting period for treatment of preexisting conditions. Rescission Of Contract When a policy holder misstates, provides misleading information or omits any material information on his or her application, BCBSAZ may rescind (declare null and void) any policy issued to the policy holder as of the effective date of the policy. A misrepresentation or nondisclosure is deemed “material” if BCBSAZ would not have issued the policy had there been no misrepresentation or non-disclosure. When a policy is rescinded, you are responsible for all medical expenses incurred in excess of premiums paid to BCBSAZ. BCBSAZ reserves the right to investigate incidents of misrepresentation or non-disclosure at any time while you are covered by this policy. Replacing Your Policy Your outline of coverage describes the Medicare supplement benefit policies available from BCBSAZ. You may transfer to another BCBSAZ Medicare supplement policy that provides comparable or lesser benefits by sending a written request to BCBSAZ indicating the BCBSAZ Medicare supplement policy you wish to transfer to. Your new coverage will be effective the first day of the month after BCBSAZ receives your request.

If Senior Security coverage is discontinued by federal or state law, you will be allowed to transfer to another BCBSAZ Medicare supplement policy with comparable or lesser benefits without a break in coverage.

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Your Premium Senior Security premiums are determined by your health status at the time of enrollment, unless you qualified for guaranteed acceptance or enrolled during a legally mandated open enrollment period. Billing Options

Premium payments should be made directly to BCBSAZ on or before the due date. Premium notices will be mailed to you before each due date. You are still responsible for paying your premium, even if you do not receive a notice.

Grace Period

Premiums must be paid in advance or mailed on or before the due date. However, a grace period of 30 days will be allowed after the due date. BCBSAZ will not be liable for claims incurred during the grace period unless BCBSAZ receives your premium payment before the end of the grace period. A premium not paid when due and not paid within the grace period will be in default, and this policy will terminate as of the due date. To reapply for coverage you must:

• File an application, • Qualify for coverage, subject to BCBSAZ’s Medicare supplement medical underwriting

guidelines, and • Fulfill all terms and conditions of the new policy.

Premium Change Notification BCBSAZ reserves the right to change the premium, subject to a 30-day notice, provided like action is taken on all similar Senior Security policies.

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GRIEVANCE PROCEDURE/REQUEST FOR RECONSIDERATION If you cannot resolve an issue or you disagree with an action or decision made by BCBSAZ, you may submit a written grievance to BCBSAZ. You must send BCBSAZ your grievance request within one (1) year of the notice of the adverse benefit determination or date of occurrence if not related to a benefit determination. BCBSAZ has discretion to extend this time limit for good cause. Examples of good cause include a death in the immediate family or serious illness of you or someone in your immediate family. Good cause does not include travel for any reason other than death or serious illness as noted. With your grievance request you should tell BCBSAZ the action that you disagree with, the reason why you think BCBSAZ’s action is wrong and what you are asking BCBSAZ to do differently. You should also send BCBSAZ any documents that support your request. Level 1 Review

After receiving your grievance BCBSAZ will review the situation, including any new information brought to BCBSAZ’s attention. BCBSAZ will notify you of its decision within sixty (60) days of receiving your grievance.

Level 2 Review

If you disagree with BCBSAZ’s Level 1 decision, you may send BCBSAZ a request for a Level 2 review. You must file your request for Level 2 review within sixty (60) days of receiving BCBSAZ’s Level 1 decision. You must explain the reason for your dissatisfaction with the Level 1 decision and any additional information you think should be considered.

Generally, a BCBSAZ appellate committee will review your grievance at a regularly scheduled meeting. The appellate committee includes BCBSAZ staff and administrators who did not make the initial decision and may include external medical personnel. BCBSAZ will notify you of its Level 2 decision within sixty (60) days of the date BCBSAZ receives your Level 2 grievance. BCBSAZ may extend the Level 2 60-day limit if necessary and in accordance with applicable law. BCBSAZ will notify you of any need for an extension. Level 1 Grievances should be sent to: Customer Service Claims Department Mail Stop N104 BCBSAZ P.O. Box 13466 Phoenix, AZ 85002 Level 2 Grievances should be sent to: Medical Appeals and Grievances Coordinator Mail Stop A116 BCBSAZ P.O. Box 13466 Phoenix, AZ 85002-3466

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CONDITIONS, LIMITATIONS AND GENERAL INFORMATION Blue Cross and Blue Shield Association Policy holder hereby expressly acknowledges his or her understanding this policy (“agreement”) constitutes a contract solely between policy holder and BCBSAZ, which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the “Association”), permitting BCBSAZ to use the Blue Cross and/or Blue Shield Service Marks in the State of Arizona, and that BCBSAZ is not contracting as the agent of the Association. Policy holder further acknowledges and agrees that he or she has not entered into this agreement based upon representations by any person other than BCBSAZ and that no person, entity, or organization other than BCBSAZ shall be held accountable or liable to policy holder for any of BCBSAZ’s obligations to the policy holder created under this agreement. This paragraph shall not create any additional obligations whatsoever on the part of BCBSAZ other than those obligations created under other provisions of this agreement. Broker Commissions BCBSAZ sells health and dental coverage products either directly or through independent licensed insurance brokers. Commission payments to brokers are one of the costs factored into premiums, but BCBSAZ's premium calculation is not based on whether a product is sold directly or by a broker. BCBSAZ generally pays a commission to the broker of record or legal assignee designated by the broker until the insurance contract is terminated, the policy holder terminates his or her relationship with the broker and notifies BCBSAZ or the broker becomes ineligible for receipt of commissions. Your broker is required under the agreement with BCBSAZ to give you information on his or her commission rate with BCBSAZ. More detailed information about broker commissions and compensation to BCBSAZ employees who are Licensed Sales Representatives for BCBSAZ individual products is available for review at www.azblue.com or you may obtain a copy by calling BCBSAZ at (602) 864-4021. Confidentiality and Release of Information BCBSAZ takes confidentiality very seriously. We have processes and systems to safeguard sensitive or confidential information and to release such information only in accordance with state and federal law. If you wish to authorize someone to have access to your information, you can download the Confidential Information Release Form (CIRF) from www.azblue.com or call BCBSAZ customer service and request a hard copy of the CIRF form.

Legal Action and Applicable Law This contract is governed by, construed and enforced in accordance with the laws of the state of Arizona, without regard to conflict of laws principles, and applicable federal law. BCBSAZ has an appeals program for resolving disputes with customers. If you file a lawsuit before completing that procedure, the suit may be dismissed for failure to exhaust BCBSAZ’s administrative remedies.

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Jurisdiction and Venue Maricopa County, Arizona shall be the site of jurisdiction and venue for any legal action or other proceeding that arises out of or relates to the contract or this policy. Lawsuits by BCBSAZ Sometimes, BCBSAZ has an opportunity to join class action lawsuits, where third party payers (insurance companies) assert that an entity’s conduct resulted in higher payments by the insurance company than otherwise would have been required. BCBSAZ reviews these cases and makes a good faith decision based on the unique facts of each case whether to join the case. BCBSAZ may also bring lawsuits against vendors or other entities to recover various economic damages. When BCBSAZ participates as a plaintiff and recovers damages, those funds are not returned to individual policy holders, but are instead retained by BCBSAZ to reduce overall administrative costs. This paragraph is not intended to limit or waive any claims BCBSAZ may have against any person or entity. Member Notices and Communications BCBSAZ sends notices and other communications to policy holders by U.S. mail to the last address on file with BCBSAZ Membership Services. BCBSAZ may also elect to send some notices and communications electronically if the policy holder has consented to electronic receipt. Notice is deemed complete when sent to the policy holder’s last address of record, as follows: (1) on delivery, if hand-delivered; (2) if mailed, on the earlier of the day actually received by the policy holder or five days after deposit in the U.S. mail, postage prepaid; or (3) if transmitted electronically, on the earlier of the day of actual receipt or 24 hours after electronic transmission to the policy holder’s email address of record. Non-Assignability of Benefits The benefits contained in this policy are not assignable. You may not assign or transfer by any means the rights to receive any portion of your benefits to any person or entity. Outstanding Checks

BCBSAZ automatically voids any check issued to you as payment for a claim, or for any other purpose, if the check remains outstanding for 6 months or more from the date of issue. Payments Made in Error If BCBSAZ erroneously makes a payment or over-payment to you or on your behalf, BCBSAZ may obtain reimbursement from you or the provider or BCBSAZ may offset the amount owed against a future claim arising from any covered service. Payments made in error by BCBSAZ do not constitute a waiver concerning the claim(s) at issue or of any right of BCBSAZ to deny payment for noncovered services.

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Provider Treatment Decisions and Disclaimer of Liability While rendering services to you, providers exercise independent medical judgment. BCBSAZ’s role is limited to administration of the benefits under this policy. Your provider may recommend services or treatment not covered under this policy. You and your provider should decide whether to proceed with a service that is not covered. BCBSAZ has no control over any diagnosis, treatment, care or other services rendered by any provider and disclaims any and all liability for any loss or injury to you caused by any provider by reason of the provider’s negligence, failure to provide treatment or otherwise. Release of Records Subject to Arizona or federal law, you agree that BCBSAZ may obtain, from any provider, insurance company or third party, all records or information relating to your health, condition, treatment, prior health insurance claims or health benefit program. BCBSAZ reserves the right to reject or suspend a claim based on lack of medical information or records.

Time Limit On Claims; Notice Of Claim BCBSAZ will not be liable under the policy unless proper notice is furnished that covered services have been provided. The notice of claim report must include all data necessary for BCBSAZ to determine benefits. A claim under this policy must be filed within one (1) year from the date of processing by Medicare. BCBSAZ may deny payment of any claim that is not filed within one year from the date of processing by Medicare.

Third-Party Beneficiaries The provisions of this policy are only for the benefit of those covered under this policy. Except as may be expressly set forth in this book, no third party may seek to enforce or benefit from any provisions of this policy. Your Right to Information You have the right to inspect and copy your information and records maintained by BCBSAZ, with some limited exceptions required by law. This right is described in the Notice of Privacy Practices provided to you at the time of enrollment and available by request from BCBSAZ. If you choose to review your medical records in person, BCBSAZ will require a reasonable amount of time to research and retrieve the records before scheduling a time with you to review the records.