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1. 2009 Outline of Medicare
Supplement Coverage
Blue Cross Blue Shield of Delaware is an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association.
©2009 Blue Cross Blue Shield of Delaware.
Med Sup Outline (Rev. 02/09)

2. 2009 Medicare Supplement Program Information • This chart shows the benefits included in each of the standard Medicare
Supplement plans.
Medicare Supplement Coverage Outline: • Every company must make Plans A, B, C and F available.
Blue Cross Blue Shield of Delaware Offers Plans A, B, C, D and F • See below chart for details about ALL plans. Blue-shaded columns represent
plans offered by BCBSD.
Basic Benefits for Plans A through J: Basic Benefits for Plans K and L:
• Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Basic benefits for Plans K and L include similar
• Medical Expenses: Part B coinsurance (generally, 20% of Medicare-approved expenses) or copayments for hospital outpatient services. services as Plans A through J, but cost-sharing for the
• Blood: First three pints of blood each year are covered. basic benefits is at different levels.
Plan A Plan B Plan C Plan D Plan E Plan F Plan F* Plan G Plan H Plan I Plan J Plan J* Plan K** Plan L**
Basic Basic Benefit Basic Benefit Basic Benefit Basic Benefit Basic Benefit Basic Benefit Basic Benefit Basic Benefit Basic Benefit • 100% of Part A Hospitalization • 100% of Part A Hospitalization
Benefit Coinsurance plus coverage Coinsurance plus coverage
for 365 days after Medicare for 365 days after Medicare
benefits end benefits end
• 50% Hospice cost-sharing • 75% Hospice cost-sharing
• 50% of Medicare-eligible • 75% of Medicare-eligible
expenses for the first 3 pints expenses for the first 3 pints
of blood of blood
• 50% of Part B Coinsurance, • 75% of Part B Coinsurance,
except 100% Coinsurance for except 100% Coinsurance for
Part B Preventive Services Part B Preventive Services
Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing 50% of Skilled Nursing Facility 75% of Skilled Nursing Facility
Facility Facility Facility Facility Facility Facility Facility Facility Coinsurance Coinsurance
Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance
Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible 50% of Part A Deductible 75% of Part A Deductible
Part B Deductible Part B Deductible Part B Deductible
Part B Excess (100%) Part B Excess Part B Excess (100%) Part B Excess (100%)
(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 Recovery At-Home Recovery At-Home Recovery At-Home Recovery
Preventive Care NOT Preventive Care NOT
covered by Medicare covered by Medicare
$4,620 out-of-pocket $2,310 out-of-pocket
annual limit*** annual limit***
* Plans F and J also have an option called a high-deductible Plan F and a high-deductible Plan J. These high-deductible plans pay the same or offer **Plans K and L provide for different cost-sharing for items and services than Plans A through J. Once you reach the annual limit, the plan pays
the same benefits as Plans F and J after one has paid a calendar year $2,000 deductible. Benefits from high-deductible Plans F and J will not begin 100% of the Medicare copayments, coinsurance and deductibles for the rest of the calendar year. The out-of-pocket annual limit does not include
until out-of-pocket expenses are $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges.
expenses include the Medicare deductibles for Part A and Part B, but do not include, in Plan J, the plan’s separate foreign travel emergency deductible. ***The out-of-pocket annual limit will increase each year for inflation.
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3. 2009 Medicare Supplement Monthly Rates
Rates are based on the age of the contract holder* as of January 1, 2009, for existing customers and as of the effective date of coverage for
new customers.
Blue Cross Blue Shield of Delaware Plans and Rates
Effective January 1, 2009, through December 31, 2009
Age Plan A Plan B Plan C Plan D Plan F
Age 65 $78 $90 $126 $111 $129
Age 66 $83 $96 $135 $119 $138
Age 67 $89 $103 $144 $127 $147
Age 68 $94 $109 $153 $135 $156
Age 69 $100 $115 $162 $143 $166
Age 70 $105 $122 $171 $150 $175
Ages 71 to 75 $131 $151 $212 $187 $217
Ages 76 to 80 $151 $174 $245 $215 $250
Ages 81 to 85 $168 $194 $273 $240 $279
Over Age 85 $187 $217 $304 $268 $311
Under Age 65 $187 $217 $304 $268 $311
Not ESRD
Under Age 65 $1,176 $1,342 $1,765 $1,739 $1,853
and ESRD**
* There is a separate rate for those under age 65 with ESRD (End Stage Renal Disease).
**Plans available beginning January 12, 2009. For rates please contact BCBSD Customer Service at 302.429.0260 or 800.633.2563.
Premium Information Read Your Policy Very Carefully Policy Replacement Complete Answers Are Very Important
Blue Cross Blue Shield of Delaware (BCBSD) can only raise your This is only an outline, describing your policy’s most important features. The If you are replacing another health insurance policy, do not cancel When you fill out the application for the new policy, be sure to answer
premium if we raise the premium for all policies like yours in this policy is your insurance contract. You must read the policy itself to understand it until you have actually received your new policy and are sure you truthfully and completely all questions about your medical and health
state. all of the rights and duties of both you and your insurance company. want to keep it. history. The company may cancel your policy and refuse to pay any
Premiums vary by the following categories: claims if you leave out or falsify important medical information.
Right To Return Policy Notice
• Ages 65, 66, 67, 68, 69, 70 Review the application carefully before you sign it. Be certain all
• Ages 71 to 75 If you find that you are not satisfied with your policy, you may return it to: This policy may not fully cover all of your medical costs. BCBSD
information has been properly recorded.
• Ages 76 to 80 BCBSD is not connected with Medicare. This Outline of Coverage does
• Ages 81 to 85 PO Box 1991 not give all the details of Medicare coverage. Contact your local
• Over Age 85 Wilmington, DE 19899-1991 Social Security office or consult the Medicare and You handbook
• Under Age 65 Not ESRD for more details.
• Under Age 65 and ESRD 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 all of your
Disclosures payments.
Use this outline to compare benefits and premiums among policies.
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4. 2009 Summary of Benefits
Services Plan A Plan B Plan C Plan D Plan F
Medicare Pays
Medicare Part A Hospital Services Per Benefit Period Plan A Pays You Pay Plan B Pays You Pay Plan C Pays You Pay Plan D Pays You Pay Plan F Pays You Pay
Hospitalization*— Semiprivate room / board, general nursing, miscellaneous All but $1,068 $0 $1,068 $1,068 $0 $1,068 $0 $1,068 $0 $1,068 $0
services and supplies Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible
First 60 days
61st thru 90th day All but $267 a day $267 a day $0 $267 a day $0 $267 a day $0 $267 a day $0 $267 a day $0
91st day and after: While using 60 lifetime reserve days All but $534 a day $534 a day $0 $534 a day $0 $534 a day $0 $534 a day $0 $534 a day $0
Once lifetime reserve days are used: $0 100% of Medicare- $0** 100% of Medicare- $0** 100% of Medicare- $0** 100% of Medicare- $0** 100% of Medicare- $0**
Additional 365 days Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses Eligible Expenses
Beyond the additional 365 days $0 $0 All Costs $0 All Costs $0 All Costs $0 All Costs $0 All Costs
Skilled Nursing Facility Care* — You must meet Medicare’s requirements, All approved amounts $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
including being in a hospital for at least three days and entering a
Medicare-approved facility within 30 days after leaving the hospital.
First 20 days
21st thru 100th day All but $133.50 a day $0 Up to $133.50 a day $0 Up to $133.50 a day Up to $133.50 a day $0 Up to $133.50 a day $0 Up to $133.50 a day $0
101st day and after $0 $0 All Costs $0 All Costs $0 All Costs $0 All Costs $0 All Costs
Blood — First three pints $0 3 pints $0 3 pints $0 3 pints $0 3 pints $0 3 pints $0
Additional Amounts 100% $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Hospice Care — Available providing your doctor certifies you are terminally ill and All but very limited $0 Balance $0 Balance $0 Balance $0 Balance $0 Balance
you elect to receive these services. coinsurance for
outpatient drugs
and inpatient
respite care
Medicare Part B Medical Services Per Calendar Year
Medical Expenses — In and out of the hospital and outpatient hospital treatment, such $0 $0 $135 $0 $135 $135 $0 $0 $135 $135 $0
as: Part B Deductible Part B Deductible Part B Deductible Part B Deductible Part B Deductible
• Diagnostic tests
• Durable medical equipment
• Inpatient / outpatient medical and surgical supplies
• Physical and speech therapy
• Physician services
First $135 of Medicare-approved amounts†
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Generally 20% $0 Generally 20% $0 Generally 20% $0
Part B Excess Charges (above Medicare-approved amounts) $0 $0 All Costs $0 All Costs $0 All Costs $0 All Costs 100% $0
Blood — First three pints $0 All Costs $0 All Costs $0 All Costs $0 All Costs $0 All Costs $0
Next $135 Medicare-approved amounts† $0 $0 $135 $0 $135 $135 $0 $0 $135 $135 $0
Part B Deductible Part B Deductible Part B Deductible Part B Deductible Part B Deductible
Remainder of Medicare-approved amounts 80% 20% $0 20% $0 20% $0 20% $0 20% $0
Clinical Laboratory Services — Tests for diagnostic services 100% $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
* 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
5 balance based on any difference between its billed charges and the amount Medicare would have paid. † Once you have been billed $135 of Medicare-approved amounts for covered services, your Part B Deductible will have been met for the calendar year. 6

5. 2009 Summary of Benefits
Services Plan A Plan B Plan C Plan D Plan F
Medicare Pays
Medicare Parts A and B Plan A Pays You Pay Plan B Pays You Pay Plan C Pays You Pay Plan D Pays You Pay Plan F Pays You Pay
Home Health Care 100% $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
Medicare-approved services:
Medically necessary skilled care services and medical supplies
Durable Medical Equipment $0 $0 $135 $0 $135 $135 $0 $0 $135 $135 $0
First $135 of Medicare-approved amounts† Part B Part B Part B Part B Part B
Deductible Deductible Deductible Deductible Deductible
Remainder of Medicare-approved amounts 80% 20% $0 20% $0 20% $0 20% $0 20% $0
Other Benefits Not Covered By Medicare
Foreign Travel Benefits — Not Covered By Medicare $0 $0 All Costs $0 All Costs $0 $250 $0 $250 $0 $250
Medically necessary emergency care services beginning during the first 60 days of each trip
outside the USA:
First $250 Each Calendar Year
Remainder of Charges $0 $0 All Costs $0 All Costs 80% to a lifetime 20% and amount 80% to a lifetime 20% and 80% to a lifetime 20% and amount
maximum benefit of over the $50,000 maximum benefit of amount over maximum benefit of over the $50,000
$50,000 lifetime maximum $50,000 the $50,000 $50,000 lifetime maximum
lifetime
maximum
At-Home Recovery Services — Not Covered By Medicare $0 $0 All Costs $0 All Costs $0 All Costs Actual Balance $0 All Costs
Home Care certified by your doctor, for personal care during recovery from injury or sickness charges up
for which Medicare has approved a Home Care Treatment Plan: to $40 a visit
Benefit for Each Visit
Number of Visits Covered $0 $0 All Costs $0 All Costs $0 All Costs Up to the number Balance $0 All Costs
(must be received within eight weeks of last Medicare-approved visit) of Medicare
approved visits.
Not to exceed 7
visits each week.
Calendar Year Maximum $0 $0 All Costs $0 All Costs $0 All Costs $1,600 Balance $0 All Costs
* A Benefit Period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out † Once you have been billed $135 of Medicare-approved amounts for covered services, your Part B Deductible will have
of the hospital and have not received skilled care in any other facility for 60 days in a row. been met for the calendar year.
** 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.
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6. Notes Notes
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