Required Statements and Disclosures

This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I and J are no longer for sale.

Read Your Policy Very Carefully

This Outline of Medicare Supplement Coverage describes your policy's most important features for comparison. The policy you receive after you enroll is your insurance contract. Please read the policy to understand the rights and duties for you and for Blue Cross and Blue Shield of Kansas (BCBSKS).

Know Your Right to Return Your Policy

If you are not satisfied with your policy, you may return it to:

Note: If you return your policy within 30 days after you receive it, BCBSKS will treat the policy as if it had never been issued and return any applicable payments.

Replacing Your Current Policy

If you are replacing another health insurance policy, do NOT cancel it until you are in possession of your new policy and are sure you want to keep it.

Complete Your Enrollment Form Carefully

You will need to complete an enrollment form for your new policy. If you are applying for Plan 65 or Plan 65-Select coverage more than six months after the effective date of your Medicare Part B coverage, you may need to answer questions on the enrollment form about your medical and health history. BCBSKS may cancel your policy and refuse to pay claims if you leave out or falsify important medical information.

Review the enrollment form carefully and make sure all information has been properly recorded before you sign.

Easy Renewal

You may renew this Plan 65 policy as long as you live by paying the premium on time. We cannot cancel or refuse to renew your policy, or place any restrictions on it, other than for non-payment or for fraudulent misstatements made by you in your applications for the policy.

Simple Cancellation Terms

You may cancel this policy at any time by written notice delivered or mailed to BCBSKS, effective upon receipt of such notice or on such late date as may be specified in such notice. In the event of cancellation or death of the insured, BCBSKS will promptly return the unearned portion of any premium paid. The earned premium shall be computed on a pro-rata basis last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued pro-rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.

Premium Information

Any premium rate increase must be implemented on a class basis in Kansas. No rate adjustment may be made on an individual basis.

Plan 65 Policy Numbers:

Benefit Plan A # 95-1052 
Benefit Plan C # 95-1053 
Select Benefit Plan C # 95-1054 
Benefit Plan F # 95-1055 
Select Benefit Plan F # 95-1056 
Benefit Plan G # 95-1061 
Select Benefit Plan G # 95-1062 
Benefit Plan K # 95-1057 
Select Benefit Plan K # 95-1058 
Benefit Plan N # 95-1060

Important Notices:

• This policy may not fully cover all your medical costs.
• Blue Cross and Blue Shield of Kansas is not connected with or endorsed by the U.S. Government or the Federal Medicare Program.
• This section does not give all details of Medicare coverage. Contact your local Social Security Office or consult “Medicare and You” handbook on the Medicare website for more details.
• For costs and details of coverage, including exclusions, reductions or limitations and the terms under which the policy may be continued in force, write the company.
• Contact for this coverage:

Exclusions…

Here is a list of key services not covered by Plan 65 Benefit Plans.

• Custodial nursing home care.
• Intermediate nursing home care costs.
• Most dental care and hospital admissions for such care. Examples are treatment, filling, removal or replacement of teeth, root canal therapy, surgery for impacted teeth, and other surgical procedures involving the teeth or structures directly supporting the teeth.
• Routine physical examinations and tests, routine foot care, and immunizations except injection of pneumococcal vaccine, mammograms and prostate exams.
• Hearing aids and examinations for them, or consultations about them.
• Eyeglasses or contact lenses and examinations for them, or consultations about them, unless for replacement of the lens following cataract surgery.
• Benefits considered medically unnecessary by a committee of doctors representing Medicare and Blue Cross and Blue Shield of Kansas will not be paid.

Questions?

Contact us about Plan 65 or Plan 65-Select Benefit Plans at 1-800-752-6650 outside Topeka or 785-291-4301 in Topeka.