Summary of Benefits

Basic Medicare Supplement (Basic Medicare Blue) Coverage:	Extended Basic Medicare Supplement (Extended Basic Blue) Coverage: This product covers 100% of all eligible charges after a member total annual out-of-pocket maximum of $1,000 for eligible services.
Hospital Services • Optional coverage of Medicare Part A deductible available • Medicare Part A coinsurance • Medicare-eligible services in full after Medicare benefits are exhausted You pay Part A deductible	Hospital Services • Medicare Part A deductible • Medicare Part A coinsurance • Medicare-eligible services in full after Medicare are exhausted You pay nothing
Skilled Nursing Care • Part A coinsurance You pay all charges after the 100th day	Skilled Nursing Care • Part A coinsurance • 80% for eligible charges in days 101-120 You pay 20% of eligible charges for days 101 through 120, then you pay all charges
Hospice and Respite Care • Covered in full by Medicare • Any remaining Medicare-eligible charges covered in full	Hospice and Respite Care • Covered in full by Medicare • Any remaining Medicare-eligible charges covered in full
Home Health Care and Medical Supplies • Covered in full by Medicare You pay nothing	Home Health Care and Medical Supplies • Covered in full by Medicare You pay nothing
Emergency Services • Same as Basic Medicare Blue Hospital and Medical Services coverage	Emergency Services • Same as Extended Basic Blue Hospital and Medical Services coverage
Medical Services, Outpatient Services and Durable Medical Equipment • Optional coverage of Part B deductible available • Optional rider for remaining balances on nonassigned claims • 20% of Medicare’s approved charge You pay Part B deductible and any remaining charges	Medical Services, Outpatient Services and Durable Medical Equipment • Part B deductible; 20% of Medicare’s approved charge and 80% of the remaining eligible charges • Some extended benefits up to 80% of eligible charges You pay any remaining charges
Foreign Medical Services • 80% of eligible services You pay any remaining charges	Foreign Medical Services • 80% of eligible services You pay any remaining charges
Preventive Services (Optional Benefit) • Annual physical exam, eye exam and hearing screening • Up to $120 benefit per year for members enrolling with effective dates on or after 6/1/2010	Preventive Services (Included Benefit) • Annual physical exam, eye exam and hearing screening, up to $120 benefit per year You pay any remaining charges