Plan F

MediGap-65 PLAN F

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* 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.

** Notice: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

SERVICES	MEDICARE PAYS	PLAN F PAYS	YOU PAY
Hospitalization* Semiprivate room and board, general nursing and miscellaneous services and supplies
• First 60 days	All but $1,100	$1,100 (Part A Deductible)	$0
• 61st thru 90th day	All but $275 a day	$275 a day	$0
• 91st day and after:
— While using 60 lifetime reserve days	All but $550 a day	$550 a day	$0
— Once lifetime reserve days are used:
— Additional 365 days	$0	100% of Medicare Eligible Expenses	$0**
— Beyond the additional 365 days	$0	$0	All costs
Skilled Nursing Facility Care* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-Approved facility within 30 days after leaving the hospital
• First 20 days	All approved amounts	$0	$0
• 21st thru 100th day	All but $137.50 a day	Up to $137.50 a day	$0
• 101st day and after	$0	$0	All costs
Blood
• First 3 pints	$0	3 pints	$0
• Additional amounts	100%	$0	$0
Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services	All but very limited coinsurance for out-patient drugs and inpatient respite care	$0	Balance

*Once you have been billed $155 of Medicare-Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year

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SERVICES	MEDICARE PAYS	PLAN F PAYS	YOU PAY
Medical Expenses-In Or Out Of 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 $155 of Medicare-Approved Amounts*	$0	$155 (Part B Deductible)	$0
• Remainder of Medicare-Approved Amounts	Generally 80%	Generally 20%	$0
Part B Excess Charges – (Above Medicare-Approved Amounts)	$0	100%	$0
Blood
• First 3 pints	$0	All costs	$0
• Next $155 of Medicare-Approved Amounts*	$0	$155 (Part B Deductible)	$0
• Remainder of Medicare-Approved Amounts	80%	20%	$0
Clinical Laboratory Services
• Tests for diagnostic services	100%	$0	$0
Medicare Parts A and B
Home Health CareMedicare-Approved Services
• Medically necessary skilled care services and medical supplies	100%	$0	$0
• Durable medical equipment
— First $155 of Medicare-Approved Amounts*	$0	$155 (Part B Deductible)	$0
— Remainder of Medicare-Approved Amounts	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

CareFirst BlueCross BlueShield

Individual Market Division

10455 Mill Run Circle, 4th floor, Owings Mills, Maryland 21117

A private not-for-profit health service plan incorporated under the laws of the State of Maryland.

CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

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Plan F

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