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Lifewise Health Plan of Oregon Medicare Supplement Plan Information
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Lifewise Health Plan of Oregon Medicare Supplement Rates Rates effective 1/1/2012 Plan A Plan F High Ded. Plan F Plan N Ages 65-69 $140 $185 $70 $138 Ages 70-74 $179 $236 $89 $175 Age 75+ $210 $278 $105 $208 Benefits Plan A Plan F High Ded. Plan F Plan N Medicare Part A Coinsurance and Hospital Benefits Medicare Part A Deductible   Medicare Part B Coinsurance or Co-payment 3 Medicare Part B Deductible     Medicare Part B Excess Charges     Blood (First Three Pints) Hospice Care Coinsurance or Co-payment Skilled Nursing Coinsurance   Foreign Travel Emergency (Up to Plan Limits)3   Medicare Preventive Care Part B Coinsurance

1. Medigap Plan F offers a high deductible option. You must pay for Medicare-covered costs up to the high-deductible amount ($2,070 in 2012) 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 deductible for foreign travel emergency ($250 per year).
4. After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($140 in 2012) the plan pays 100% of covered services for the rest of the calendar year (This applies only to plans K & L)
5. Modified Plan F offers an individual assistance program, as well as coverage for preventive dental care (available in some states)

• 2012 Out of Pocket Limit for Plan K is $4,660.
• 2012 Out of Pocket Limit for Plan L is $2,330.