Outline of Medicare Supplement Coverage

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					                                                          Outline of Medicare Supplement Coverage
            Blue Cross Blue Shield of Missouri is the name RightCHOICE® Managed Care, Inc. (RIT) uses to do business in most of Missouri. RIT administers benefits
           underwritten by Healthy Alliance® Life Insurance Company (HALIC). RIT and HALIC are independent licensees of the Blue Cross and Blue Shield Association.

Medicare Supplement insurance can be sold in only 10 standard plans plus two high deductible plans. This chart shows the benefits included in each plan.
Every company must make available Plan “A.” Some plans may not be available in Missouri.
Blue Cross Blue Shield of Missouri offers Plans A, B, C, D, F and High-Deductible Plan F. Our rates for these plans are on the next page.
The following Basic Benefits are included in all plans:
         For Hospitalization:      Full coverage of your Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
         For Medical Expenses: Full coverage of your Part B coinsurance (20% of Medicare-approved expenses).
         For Blood:                Full coverage of the first three pints of blood each year.

         A                  B               C                  D                 E              F      F
                                                                                                       F*             G                  H                  I              J            J*
  Basic               Basic         Basic              Basic              Basic             Basic              Basic             Basic              Basic             Basic
  Benefits            Benefits      Benefits           Benefits           Benefits          Benefits           Benefits          Benefits           Benefits          Benefits
                                    Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing
                                    Coinsurance     Coinsurance     Coinsurance     Coinsurance     Coinsurance     Coinsurance     Coinsurance     Coinsurance
                      Part A        Part A             Part A             Part A            Part A             Part A            Part A             Part A            Part A
                      Deductible    Deductible         Deductible         Deductible        Deductible         Deductible        Deductible         Deductible        Deductible
                                    Part B                                                  Part B                                                                    Part B
                                    Deductible                                              Deductible                                                                Deductible
                                                                                            Part B        Part B                                    Part B        Part B
                                                                                            Excess (100%) Excess (80%)                              Excess (100%) Excess (100%)
                                    Foreign Travel Foreign Travel         Foreign Travel Foreign Travel        Foreign Travel Foreign Travel        Foreign Travel    Foreign Travel
                                    Emergency      Emergency              Emergency      Emergency             Emergency      Emergency             Emergency         Emergency
                                                       At-Home                                                 At-Home                              At-Home           At-Home
                                                       Recovery                                                Recovery                             Recovery          Recovery
                                                                          Preventive Care                                                                             Preventive Care

* Plans F and J also have an option called a High-Deductible Plan F (SmartChoice) and High-Deductible Plan J. These high-deductible plans pay the same or offer the same benefits as
  Plans F and J after you have paid a $1,790 deductible each year. Benefits from High-Deductible Plans F and J will not begin until out-of-pocket expenses are $1,790. Out-of-pocket
  expenses for this deductible are expenses that would ordinarily be paid by Blue Horizons Medicare Supplement. These expenses include the Medicare deductibles for Part A and Part B,
  but do not include, in Plan J, the separate prescription drug deductible or, in Plans F and J, the separate deductible for foreign travel emergency care.

HA/MK-408B rev 8/05                                                                                                                                                AMK-617B rev 10/05    02243
                            Blue Horizons Medicare Supplement
                                  Monthly Issue-Age Rates for 2006
With issue-age rates, if you buy the policy at age 65, you will always pay the premium the company charges
65-year-old customers who originally bought the same plan at the same time you did. The rates for all ages are
subject to change each year.

                                                                                            SmartChoice
              Plan A         Plan B         Plan C         Plan D          Plan F          High Deductible
                                                                                               Plan F
  64 and
  under       $ 91.51        $125.97        $154.13         $131.03        $152.60               $54.10
  65          $ 87.35        $116.50        $141.25         $126.35        $146.85               $48.80
  66          $ 88.40        $117.70        $142.65         $127.75        $148.35               $50.35
  67          $ 90.30        $120.60        $146.30         $130.90        $152.05               $51.80
  68          $ 92.50        $123.50        $149.90         $134.20        $155.90               $53.25
  69          $ 94.80        $126.80        $153.75         $137.80        $159.90               $54.55
  70          $ 97.35        $130.35        $158.15         $141.70        $164.40               $55.75
  71          $ 99.65        $133.65        $162.10         $145.20        $168.45               $57.00
  72          $101.95        $136.85        $166.10         $148.80        $172.65               $58.25
  73          $103.95        $139.65        $169.45         $151.85        $176.20               $59.35
  74          $105.95        $142.30        $172.85         $154.80        $179.70               $60.30
  75          $107.85        $145.00        $176.25         $157.85        $183.25               $61.65
  76          $109.85        $147.75        $179.60         $160.90        $186.80               $62.90
  77          $111.85        $150.45        $182.90         $163.95        $190.30               $64.15
  78          $113.50        $152.70        $185.70         $166.45        $193.15               $65.40
  79          $115.10        $155.05        $188.50         $169.05        $196.00               $66.60
  80          $116.75        $157.30        $191.25         $171.45        $198.85               $67.85
  81          $118.35        $159.55        $194.10         $174.05        $201.75               $69.30
  82          $120.00        $161.90        $196.90         $176.60        $204.55               $70.90
  83          $121.40        $163.70        $199.10         $178.65        $207.05               $72.45
  84          $122.75        $165.65        $201.40         $180.70        $209.45               $74.00
  85          $124.10        $167.45        $203.80         $182.80        $211.90               $75.45
  86          $125.50        $169.40        $206.10         $184.75        $214.30               $77.05
  87          $126.85        $171.20        $208.45         $186.85        $216.85               $78.50
  88          $129.25        $174.00        $211.70         $189.90        $220.25               $79.95
  89          $131.15        $176.65        $215.10         $192.80        $223.75               $81.40
  90          $133.05        $179.45        $218.40         $195.85        $227.20               $82.75
  91          $134.95        $182.10        $221.70         $198.95        $230.75               $84.35
  92          $136.80        $184.90        $225.00         $201.85        $234.15               $85.80
  93          $164.65        $223.40        $272.10         $244.50        $283.25               $87.25

                                Monthly Community Rates for 2006
With community rates, the premium is the same for all customers age 65 and over who buy the plan, regardless
of their age. Rates for those age 64 and under are the same as those listed above as issue age rates. The rates for
all ages are subject to change each year.

       Plan A                 Plan B                  Plan C                Plan D                 Plan F
       $97.34                $148.67                  $189.21              $148.32                $162.73
                                                                                                               02243
Disclosures
Use the information in this packet to compare benefits and premiums among Medicare
Supplement plans.

Read Your Policy Very Carefully
This packet of information only describes your policy’s most important features. When you
enroll, we will send you a more detailed benefit summary and a policy. The policy is your
contract. You must read the policy, itself, to understand all the rights and duties of both you
and your health benefits company.

Right to Return Policy
If you are not satisfied with your policy when you receive it, you may return it to
Blue Cross Blue Shield of Missouri, 1831 Chestnut, St. Louis, MO 63103-2275. If you send
the policy back to us within 30 days after you receive it, we will treat the policy as if it had
never been issued and return your premium, if already paid, in full.

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

Notice
I   This policy may not fully cover all of your medical costs.
I   Neither Blue Cross Blue Shield of Missouri nor its agents are connected with Medicare.
I   This packet of information does not give all the details of Medicare coverage. Contact
    your local Social Security office or consult “The Medicare Handbook” for more details.

Complete Answers Are Very Important
When you fill out the application for a Medicare Supplement plan, be sure to answer
truthfully and completely all questions about your medical and health history. The company
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.




                                               3
Plan A
Medicare (Part A) Hospital Services — Per Benefit Period
*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.

                                                                            With Plan A,           With Plan A,
             Services and Supplies                   Medicare Pays            We Pay                You Pay
 Hospitalization:
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
   First 60 days                                     All but $952          $0                     $952 (Part A
                                                                                                     deductible)
   61st thru 90th day                                All but $238 a day    $238 a day             $0
   91st day and after:
     — While using 60 lifetime reserve days          All but $476 a day    $476 a day             $0
     — Once lifetime reserve days are used:
         Additional 365 days                         $0                    100% of Medicare-      $0
                                                                              eligible expenses
         Beyond the Additional 365 days              $0                    $0                     All costs
 Skilled Nursing Facility Care:
 You must meet Medicare’s requirements, includ-
 ing 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 amts.    $0                     $0
   21st thru 100th day                               All but $119 a day    $0                     Up to $119 a day
   101st day and after                               $0                    $0                     All costs
 Blood:
   First 3 pints                                     $0                    3 pints                $0
   Additional amounts                                100%                  $0                     $0
 Hospice Care:
 Available as long as your doctor certifies you      All but very limited $0                      Balance
 are terminally ill and you elect to receive         coinsurance for out-
 these services                                      patient drugs and in-
                                                     patient respite care

Medicare (Part B) Medical Services — Per Calendar Year
*Once you have been billed $124 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.
                                                                            With Plan A,           With Plan A,
                      Services                       Medicare Pays            We Pay                You Pay
 Medical Expenses — in or out of the hospital,
 and outpatient hospital treatment:
 Physician’s services, inpatient and outpatient
 medical and surgical services and supplies,
 physical and speech therapy, diagnostic tests,
 durable medical equipment
   First $124 of Medicare-approved amounts*          $0                    $0                     $124 (Part B
                                                                                                    deductible)
   Remainder of Medicare-approved amounts            80%                   20%                    $0
   Part B excess charges
     (above Medicare-approved amounts)               $0                    $0                     All costs

                                                            4
Medicare (Part B) — Plan A continued
                                                                   With Plan A,    With Plan A,
                     Services                     Medicare Pays      We Pay         You Pay
Blood:
  First 3 pints                                   $0              All costs       $0
  Next $124 of Medicare-approved amounts*         $0              $0              $124 (Part B
                                                                                     deductible)
  Remainder of Medicare-approved amounts          80%             20%             $0
Clinical Laboratory Services —
Blood tests for diagnostic services               100%            $0              $0


Medicare (Parts A & B)
                                                                   With Plan A,    With Plan A,
                     Services                     Medicare Pays      We Pay         You Pay
Home Health Care:
Services covered by Medicare
  Medically necessary skilled care services
     and medical supplies                         100%            $0              $0
  Durable medical equipment
     First $124 of Medicare-approved amounts*     $0              $0              $124 (Part B
                                                                                    deductible)
  Remainder of Medicare-approved amounts          80%             20%             $0
At-home recovery services — not covered
by Medicare
  Home care certified by your doctor, for
    personal care during recovery from an
    injury or sickness for which Medicare
    approved a home care treatment plan
  Benefit for each visit                          $0              $0              All costs
  Number of visits covered
    (Must be received within 8 weeks
     of last Medicare-approved visit)             0
  Calendar-year maximum                           $0


Other Benefits
                                                                   With Plan A,    With Plan A,
                     Services                     Medicare Pays      We Pay         You Pay
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              All costs
  Remainder of charges                            $0              $0




                                                         5
Plan B
Medicare (Part A) Hospital Services — Per Benefit Period
*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.

                                                                            With Plan B,           With Plan B,
             Services and Supplies                   Medicare Pays            We Pay                You Pay
 Hospitalization:
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
   First 60 days                                    All but $952           $952 (Part A           $0
                                                                             deductible)
   61st thru 90th day                               All but $238 a day     $238 a day             $0
   91st day and after:
     — While using 60 lifetime reserve days         All but $476 a day     $476 a day             $0
     — Once lifetime reserve days are used:
         Additional 365 days                        $0                     100% of Medicare-      $0
                                                                              eligible expenses
         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 amts.     $0                     $0
    21st thru 100th day                             All but $119 a day     $0                     Up to $119 a day
    101st day and after                             $0                     $0                     All costs
 Blood:
   First 3 pints                                    $0                     3 pints                $0
   Additional amounts                               100%                   $0                     $0
 Hospice Care:
 Available as long as your doctor certifies you     All but very limited $0                       Balance
 are terminally ill and you elect to receive        coinsurance for out-
 these services                                     patient drugs and in-
                                                    patient respite care

Medicare (Part B) Medical Services — Per Calendar Year
*Once you have been billed $124 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.
                                                                            With Plan B,           With Plan B,
                      Services                       Medicare Pays            We Pay                You Pay
 Medical Expenses — in or out of the hospital,
 and outpatient hospital treatment:
 Physician’s services, inpatient and outpatient
 medical and surgical services and supplies,
 physical and speech therapy, diagnostic tests,
 durable medical equipment
   First $124 of Medicare-approved amounts*         $0                     $0                     $124 (Part B
                                                                                                    (deductible)
   Remainder of Medicare-approved amounts           80%                    20%                    $0
   Part B excess charges
     (above Medicare-approved amounts)              $0                     $0                     All costs

                                                           6
Medicare (Part B) — Plan B continued
                                                                   With Plan B,    With Plan B,
                     Services                     Medicare Pays      We Pay         You Pay
Blood:
  First 3 pints                                   $0              All costs       $0
  Next $124 of Medicare-approved amounts*         $0              $0              $124 (Part B
                                                                                     deductible)
  Remainder of Medicare-approved amounts          80%             20%             $0
Clinical Laboratory Services —
Blood tests for diagnostic services               100%            $0              $0


Medicare (Parts A & B)
                                                                   With Plan B,    With Plan B,
                     Services                     Medicare Pays      We Pay         You Pay
Home Health Care:
Services covered by Medicare
  Medically necessary skilled care services
     and medical supplies                         100%            $0              $0
  Durable medical equipment
     First $124 of Medicare-approved amounts*     $0              $0              $124 (Part B
                                                                                    deductible)
  Remainder of Medicare-approved amounts          80%             20%             $0
At-home recovery services — not covered
by Medicare
  Home care certified by your doctor, for
    personal care during recovery from an
    injury or sickness for which Medicare
    approved a home care treatment plan
  Benefit for each visit                          $0              $0              All costs
  Number of visits covered
    (Must be received within 8 weeks
     of last Medicare-approved visit)             0
  Calendar-year maximum                           $0


Other Benefits
                                                                   With Plan B,    With Plan B,
                     Services                     Medicare Pays      We Pay         You Pay
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              All costs
  Remainder of charges                            $0              $0




                                                         7
Plan C
Medicare (Part A) Hospital Services — Per Benefit Period
*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.
                                                                            With Plan C,           With Plan C,
             Services and Supplies                   Medicare Pays            We Pay                You Pay
 Hospitalization:
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
   First 60 days                                    All but $952           $952 (Part A           $0
                                                                             deductible)
   61st thru 90th day                               All but $238 a day     $238 a day             $0
   91st day and after:
     — While using 60 lifetime reserve days         All but $476 a day     $476 a day             $0
     — Once lifetime reserve days are used:
           Additional 365 days                      $0                     100% of Medicare-      $0
                                                                              eligible expenses
           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 amts.     $0                     $0
    21st thru 100th day                             All but $119 a day     Up to $119 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    All but very limited $0                       Balance
  are terminally ill and you elect to receive       coinsurance for out-
  these services                                    patient drugs and in-
                                                    patient respite care

Medicare (Part B) Medical Services — Per Calendar Year
*Once you have been billed $124 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.
                                                                            With Plan C,           With Plan C,
                      Services                       Medicare Pays            We Pay                You Pay
 Medical Expenses — in or out of the hospital
 and outpatient hospital treatment:
 Physician’s services, inpatient and outpatient
 medical and surgical services and supplies,
 physical and speech therapy, diagnostic tests,
 durable medical equipment
   First $124 of Medicare-approved amounts*         $0                     $124 (Part B           $0
                                                                             deductible)
   Remainder of Medicare-approved amounts           80%                    20%                    $0
   Part B excess charges
     (above Medicare-approved amounts)              $0                     $0                     All costs

                                                           8
Medicare (Part B) — Plan C continued
                                                                   With Plan C,        With Plan C,
                     Services                     Medicare Pays      We Pay             You Pay
Blood:
  First 3 pints                                   $0              All costs           $0
  Next $124 of Medicare-approved amounts*         $0              $124 (Part B        $0
                                                                    deductible)
  Remainder of Medicare-approved amounts          80%             20%                 $0
Clinical Laboratory Services —
Blood tests for diagnostic services               100%            $0                  $0

Medicare (Parts A & B)
                                                                   With Plan C,        With Plan C,
                     Services                     Medicare Pays      We Pay             You Pay
Home Health Care:
Services covered by Medicare
  Medically necessary skilled care services
     and medical supplies                         100%            $0                  $0
  Durable medical equipment
     First $124 of Medicare-approved amounts*     $0              $124 (Part B        $0
                                                                    deductible)
  Remainder of Medicare-approved amounts          80%             20%                 $0
At-home recovery services — not covered
by Medicare
  Home care certified by your doctor, for
    personal care during recovery from an
    injury or sickness for which Medicare
    approved a home care treatment plan
  Benefit for each visit                          $0              $0                  All costs
  Number of visits covered
    (Must be received within 8 weeks
     of last Medicare-approved visit)             0
  Calendar-year maximum                           $0

Other Benefits
                                                                   With Plan C,        With Plan C,
                     Services                     Medicare Pays     We Pays             You Pay
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   20% and amounts
                                                                    maximum benefit     over the $50,000
                                                                    of $50,000          lifetime maximum




                                                         9
Plan D
Medicare (Part A) Hospital Services — Per Benefit Period
*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.

                                                                            With Plan D,           With Plan D,
             Services and Supplies                   Medicare Pays            We Pay                You Pay
 Hospitalization:
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
   First 60 days                                    All but $952           $952 (Part A           $0
                                                                             deductible)
   61st thru 90th day                               All but $238 a day     $238 a day             $0
   91st day and after:
     — While using 60 lifetime reserve days         All but $476 a day     $476 a day             $0
     — Once lifetime reserve days are used:
         Additional 365 days                        $0                     100% of Medicare-      $0
                                                                              eligible expenses
         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 amts.     $0                     $0
    21st thru 100th day                             All but $119 a day     Up to $119 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     All but very limited $0                       Balance
 are terminally ill and you elect to receive        coinsurance for out-
 these services                                     patient drugs and in-
                                                    patient respite care

Medicare (Part B) Medical Services — Per Calendar Year
*Once you have been billed $124 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.
                                                                            With Plan D,           With Plan D,
                      Services                       Medicare Pays            We Pay                You Pay
 Medical Expenses — in or out of the hospital,
 and outpatient hospital treatment:
 Physician’s services, inpatient and outpatient
 medical and surgical services and supplies,
 physical and speech therapy, diagnostic tests,
 durable medical equipment
   First $124 of Medicare-approved amounts*         $0                     $0                     $124 (Part B
                                                                                                    (deductible)
   Remainder of Medicare-approved amounts           80%                    20%                    $0
   Part B excess charges
     (above Medicare-approved amounts)              $0                     $0                     All costs

                                                          10
Medicare (Part B) — Plan D continued
                                                                   With Plan D,          With Plan D,
                     Services                     Medicare Pays      We Pay               You Pay
Blood:
  First 3 pints                                   $0              All costs             $0
  Next $124 of Medicare-approved amounts*         $0              $0                    $124 (Part B
                                                                                           deductible)
  Remainder of Medicare-approved amounts          80%             20%                   $0
Clinical Laboratory Services —
Blood tests for diagnostic services               100%            $0                    $0

Medicare (Parts A & B)
                                                                    With Plan D,         With Plan D,
                     Services                     Medicare Pays       We Pay              You Pay
Home Health Care:
Services covered by Medicare
  Medically necessary skilled care services
     and medical supplies                         100%            $0                    $0
  Durable medical equipment
     First $124 of Medicare-approved amounts*     $0              $0                    $124 (Part B
                                                                                          deductible)
  Remainder of Medicare-approved amounts          80%             20%                   $0
At-home recovery services — not covered
by Medicare
  Home care certified by your doctor, for
    personal care during recovery from an
    injury or sickness for which Medicare
    approved a home care treatment plan
  Benefit for each visit                          $0              Actual charges up      Balance
                                                                    to $40 a visit
  Number of visits covered                        0               Up to number of
    (Must be received within 8 weeks                                Medicare-approved
     of last Medicare-approved visit)                              visits, not to exceed
                                                                   7 each week
  Calendar-year maximum                           $0              $1,600

Other Benefits
                                                                    With Plan D,         With Plan D,
                     Services                     Medicare Pays       We Pay              You Pay
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     20% and amounts
                                                                    maximum benefit       over the $50,000
                                                                    of $50,000            lifetime maximum




                                                        11
Plan F
Medicare (Part A) Hospital Services — Per Benefit Period
*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.
                                                                             With Plan F,          With Plan F,
             Services and Supplies                   Medicare Pays            We Pay                You Pay
 Hospitalization:
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
   First 60 days                                    All but $952           $952 (Part A           $0
                                                                             deductible)
   61st thru 90th day                               All but $238 a day     $238 a day             $0
   91st day and after:
     — While using 60 lifetime reserve days         All but $476 a day     $476 a day             $0
     — Once lifetime reserve days are used:
           Additional 365 days                      $0                     100% of Medicare-      $0
                                                                              eligible expenses
           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 amts.     $0                     $0
    21st thru 100th day                             All but $119 a day     Up to $119 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    All but very limited $0                       Balance
  are terminally ill and you elect to receive       coinsurance for out-
  these services                                    patient drugs and in-
                                                    patient respite care

Medicare (Part B) Medical Services — Per Calendar Year
*Once you have been billed $124 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.
                                                                             With Plan F,          With Plan F,
                      Services                       Medicare Pays            We Pay                You Pay
 Medical Expenses — in or out of the hospital
 and outpatient hospital treatment:
 Physician’s services, inpatient and outpatient
 medical and surgical services and supplies,
 physical and speech therapy, diagnostic tests,
 durable medical equipment
   First $124 of Medicare-approved amounts*         $0                     $124 (Part B           $0
                                                                             deductible)
   Remainder of Medicare-approved amounts           80%                    20%                    $0
   Part B excess charges
     (above Medicare-approved amounts)              $0                     100%                   $0

                                                          12
Medicare (Part B) — Plan F continued
                                                                   With Plan F,        With Plan F,
                     Services                     Medicare Pays     We Pay              You Pay
Blood:
  First 3 pints                                   $0              All costs           $0
  Next $124 of Medicare-approved amounts*         $0              $124 (Part B        $0
                                                                    deductible)
  Remainder of Medicare-approved amounts          80%             20%                 $0
Clinical Laboratory Services —
Blood tests for diagnostic services               100%            $0                  $0

Medicare (Parts A & B)
                                                                   With Plan F,        With Plan F,
                     Services                     Medicare Pays     We Pay              You Pay
Home Health Care:
Services covered by Medicare
  Medically necessary skilled care services
     and medical supplies                         100%            $0                  $0
Durable medical equipment
  First $124 of Medicare-approved amounts*        $0              $124 (Part B        $0
                                                                    deductible)
  Remainder of Medicare-approved amounts          80%             20%                 $0
At-home recovery services — not covered
by Medicare
  Home care certified by your doctor, for
    personal care during recovery from an
    injury or sickness for which Medicare
    approved a home care treatment plan
  Benefit for each visit                          $0              $0                  All costs
  Number of visits covered
    (Must be received within 8 weeks
     of last Medicare-approved visit)             0
  Calendar-year maximum                           $0

Other Benefits
                                                                   With Plan F,         With Plan F,
                     Services                     Medicare Pays     We Pay               You Pay
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   20% and amounts
                                                                    maximum benefit     over the $50,000
                                                                    of $50,000          lifetime maximum




                                                        13
High-Deductible Plan F (SmartChoice)
Medicare (Part A) Hospital Services — Per Benefit Period
*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. This high-deductible plan pays the same or offers the same benefits
 as Plan F after you have paid a deductible each calendar year. Benefits from the high-deductible plan F will not begin until out-of-pocket
 expenses are $1,790. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the
 Medicare deductible for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
                                                                                          After you pay $1,790 In addition to $1,790
                Services and Supplies                            Medicare Pays             deductible, we pay deductible, you pay
 Hospitalization:
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies
   First 60 days                                                All but $952               $952 (Part A               $0
                                                                                             deductible)
    61st thru 90th day                                          All but $238 a day         $238 a day                 $0
    91st day and after:
      — While using 60 lifetime reserve days                    All but $476 a day         $476 a day                 $0
      — Once lifetime reserve days are used:
            Additional 365 days                                 $0                         100% of Medicare-          $0
                                                                                              eligible expenses
              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 amts.         $0                         $0
    21st thru 100th day                                         All but $119 a day         Up to $119 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                All but very limited $0                               Balance
  are terminally ill and you elect to receive                   coinsurance for out-
  these services                                                patient drugs and in-
                                                                patient respite care
Medicare (Part B) Medical Services — Per Calendar Year
*Once you have been billed $124 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.
                                                                                          After you pay $1,790 In addition to $1,790
                          Services                               Medicare Pays             deductible, we pay deductible, you pay
 Medical Expenses — in or out of the hospital
 and outpatient hospital treatment:
 Physician’s services, inpatient and outpatient
 medical and surgical services and supplies,
 physical and speech therapy, diagnostic tests,
 durable medical equipment
   First $124 of Medicare-approved amounts*                     $0                         $124 (Part B               $0
                                                                                             deductible)
    Remainder of Medicare-approved amounts                      80%                        20%                        $0
    Part B excess charges
      (above Medicare-approved amounts)                         $0                         100%                       $0
                                                                      14
Medicare (Part B) — High-Deductible Plan F continued
                                                                   After you pay $1,790 In addition to $1,790
                     Services                      Medicare Pays    deductible, we pay deductible, you pay
Blood:
  First 3 pints                                   $0               All costs             $0
  Next $124 of Medicare-approved amounts*         $0               $124 (Part B          $0
                                                                     deductible)
  Remainder of Medicare-approved amounts          80%              20%                   $0
Clinical Laboratory Services —
Blood tests for diagnostic services               100%             $0                    $0

Medicare (Parts A & B)
                                                                   After you pay $1,790 In addition to $1,790
                     Services                      Medicare Pays    deductible, we pay deductible, you pay

Home Health Care:
Services covered by Medicare
  Medically necessary skilled care services
     and medical supplies                         100%             $0                    $0
Durable medical equipment
  First $124 of Medicare-approved amounts*        $0               $124 (Part B          $0
                                                                     deductible)
  Remainder of Medicare-approved amounts          80%              20%                   $0
At-home recovery services — not covered
by Medicare
  Home care certified by your doctor, for
    personal care during recovery from an
    injury or sickness for which Medicare
    approved a home care treatment plan
  Benefit for each visit                          $0               $0                    All costs
  Number of visits covered
    (Must be received within 8 weeks
     of last Medicare-approved visit)             0
  Calendar-year maximum                           $0

Other Benefits — High-Deductible Plan F continued
                                                                   After you pay $1,790 In addition to $1,790
                     Services                      Medicare Pays    deductible, we pay deductible, you pay
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     20% and amounts
                                                                     maximum benefit       over the $50,000
                                                                     of $50,000            lifetime maximum




                                                        15
                             Additional Information

The Blue Cross Blue Shield of Missouri Quality Improvement Program
The Blue Cross Blue Shield of Missouri Quality Improvement Program monitors and evaluates clinical and
administrative services. The Blue Cross Blue Shield of Missouri Board of Directors has overall authority
and accountability for the Quality Improvement Program. The Operating Committee is responsible for the
Service Quality Improvement Program, and the Quality Improvement Peer Review Committee is
responsible for the Clinical Quality Improvement Program.
The Quality Improvement Peer Review Committee, which includes participating primary care physicians
and specialists, provides peer review of the clinical care of members. The Quality Improvement Peer Review
Committee reports to the Operating Committee.
Blue Cross Blue Shield of Missouri monitors and evaluates all clinical (both institutional and
non-institutional; both medical and behavioral health care) and administrative services through the Quality
Improvement Plan. The Quality Improvement Program monitors, evaluates and implements corrective
actions for improvement opportunities in the following areas: clinical care aspects, member services, provider
services, operations, and regulatory and accreditation compliance.

The Grievance Procedure
Eligible benefits for this program are based on whether Medicare covered the service. If we deny a claim in
whole or in part, the member will receive written notification (an Explanation of Benefits, or EOB) from
Blue Cross Blue Cross of Missouri, giving the reason for denial.
If the member disagrees with the denial, he or she may call the Blue Cross Blue Shield of Missouri Client
Service Center at the telephone number on the back of the identification card. A Client Services representative
will investigate the complaint. If the member is still dissatisfied, he or she may appeal the decision.
To file a grievance, the member should send a letter explaining the disagreement and include records, plus
any supporting information. Within 10 working days, we will let the member know we received the
grievance. We will try to investigate the grievance within 20 working days after receipt. If we cannot
complete the investigation within 20 days, we will notify the member in writing within that time. We will
then complete the investigation within 30 additional working days.
Within five working days after we complete the investigation, we will send the member our decision in
writing. If the member does not agree with our response to the grievance, he or she may file a second-level
grievance, which will be submitted to a grievance advisory panel. The time frames for resolving a
second-level grievance are the same as a first-level grievance.




                                                                                                      02243 rev 10/05

				
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