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Plan 65

Read Your Policy 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.

Know Your Right to Return Your Policy
If you are not satisfied with your policy, you may return it to Blue Cross and Blue Shield of Kansas at 1133 S.W. Topeka Blvd., Topeka, Kansas 66629-0001.

NOTE: If you return your policy within 30 days after you receive it, Blue Cross and Blue Shield of Kansas will treat the policy as if it had never been issued and return any applicable payments.

How to Replace Your Current Health Insurance Policy
If you are replacing your current policy with a Blue Cross and Blue Shield of Kansas 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. Blue Cross and Blue Shield of Kansas 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
Your Plan 65 Benefit Plan policy is guaranteed renewable by you during your lifetime as long as the required premiums are paid and there is no material misrepresentation of a material fact by you.

Simple Cancellation Terms
Cancel your policy at any time by sending written notice to Blue Cross and Blue Shield of Kansas. The unearned portion of any advance premiums paid will be refunded.

NOTE: Your Plan 65 Benefit Plan coverage will never be canceled by Blue Cross and Blue Shield of Kansas on the grounds of deterioration of health.

Right to Change Premiums
Blue Cross and Blue Shield of Kansas has the right to change the amount of premiums, if it does so for all contracts with the same form number issued to individuals of the same age as this contract and upon proper notification to members and filing with the Kansas Insurance Department.

Plan 65 Benefit Plan A policy number is 80-1138; Plan 65 Benefit Plan C policy number is 80-1139; Plan 65 Benefit Plan F policy number is 80-1140 and Plan 65 Benefit Plan K policy number is 95-1040. The Plan 65-Select Benefit Plan C policy number is 95-1003; the Plan 65-Select Benefit Plan F policy number is 95-1004; and the Plan 65-Select Benefit Plan K policy number is 95-1041.

Important Notices:

• This policy may not fully cover all your medical costs.
• Blue Cross and Blue Shield of Kansas is not connected with Medicare in its solicitation or issuance of coverage.
• This section does not give all details of Medicare coverage. Contact your local Social Security Office or see “The Medicare Handbook” on the Medicare Web site 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: Mark Dolsky, Vice President, Sales and Marketing, Blue Cross and Blue Shield of Kansas, 1133 S.W. Topeka Blvd., Topeka, Kansas 66629-0001.

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.
• Eye glasses or contact lenses and examinations about 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.