Zip Code* Age* Gender


Premera Blue Cross Medicare Supplement Rates
Rates Effective
March 1, 2015
Plan A Plan F Plan F High Ded Plan N
Premera Blue Cross $146.00 $183.00 $75.00 $144.00
Benefits Plan A Plan F Plan F High Ded Plan N
Part B Coinsurance 100 100 100 100
Skilled Nursing 100 100 100 100
Part B Excess 100 100
Foreign Travel 80 80 80 80
Part A Deductible 1260
Part B Deductible 147 147
Part B Excess Charges Not Covered Covered Covered Not Covered
Doctor/Hospital Choice Any Doctor or medical provider that accepts Medicare Any Doctor or medical provider that accepts Medicare Any Doctor or medical provider that accepts Medicare Any Doctor or medical provider that accepts Medicare
Office Visit No Charge after deductible; Excess Charges possible No Charge No Charge Up to $20 plus Excess Charges
OOP Maximum No Limit No Limit No Limit No Limit
Rx Coverage Not Covered Not Covered Not Covered Not Covered
Foreign Travel 80% 80% 80% 80%
Hospitalization No charge after Part A deductible for Days 1-60; No charge for Days 61-90; No charge for Days 91-150 (Lifetime Reserve); No charge for Additional 365 days after reserve. No charge for Days 1-60; No charge for Days 61-90; No charge for Days 91-150 (Lifetime Reserve); No charge for Additional 365 days after reserve. No charge for Days 1-60; No charge for Days 61-90; No charge for Days 91-150 (Lifetime Reserve); No charge for Additional 365 days after reserve. No charge for Days 1-60; No charge for Days 61-90; No charge for Days 91-150 (Lifetime Reserve); No charge for Additional 365 days after reserve.
Outpatient Surgery No Charge after deductible; Excess Charges possible No Charge No Charge No Charge after Part B Deductible
Skilled Nursing Facility First 20 days $0; 21st thru 100th day $157.50 per day; after 100 days you pay all No Charge for the first 100 days No Charge for the first 100 days No Charge first 100 days
Hospice No Charge No Charge No Charge No Charge
Blood No Charge No Charge No Charge No Charge
Physician's Services No Charge after deductible; Excess Charges possible No Charge No Charge Up to $20 plus Excess Charges
Emergency Room No Charge after deductible; Excess Charges possible No Charge No Charge Up to $50 plus Excess Charges
Ambulance Services No Charge after deductible; Excess Charges possible No Charge No Charge No Charge after Part B Deductible
Urgent Care No Charge after deductible; Excess Charges possible No Charge No Charge Up to $20 plus Excess Charges
Outpatient Lab/X-Ray No Charge after deductible; Excess Charges possible No Charge No Charge No Charge after Part B Deductible
Outpatient Surgery No Charge after deductible; Excess Charges possible No Charge No Charge No Charge after Part B Deductible
Outpatient Rehab Service No Charge after deductible; Excess Charges possible No Charge No Charge Up to $20 plus Excess Charges
Home Health Care No Charge No Charge No Charge No Charge
Durable Medical Equipment No Charge after deductible; Excess Charges possible No Charge No Charge No Charge after Part B Deductible
Hospice No Charge No Charge No Charge No Charge
Blood No Charge after Part B Deductible No Charge No Charge No Charge after Part B Deductible
  1. Medigap Plan F offers a high deductible option. You must pay for Medicare-covered costs up to the high-deductible amount ($2,180 in 2015) before your Medigap policy pays anything
  2. 100% part B coinsurance except up to $20 copayment for office visits and up to $50 copayment for ER.
  3. You must also pay a separate $250 deductible for foreign travel emergency and there is a $50,000 lifetime maximum benefit.
  4. After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($147 in 2015) the plan pays 100% of covered services for the rest of the calendar year (This applies only to plans K & L) & [Excess charges do to apply to maximum out of pocket]
  5. Modified Plan F offers an individual assistance program, as well as coverage for preventive dental care (available in some states)
  • 2015 Out of Pocket Limit for Plan K is $4,940.
  • 2015 Out of Pocket Limit for Plan L is $2,470.