Common use of Basic Benefits Clause in Contracts

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 deductible. Benefits fromhigh deductible plan F will not begin until out-of-pocket expenses exceed $2,490. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,620; paid at 100% after limit reached Out-of- pocket limit $3,310; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 deductible. Benefits fromhigh deductible plan F will not begin until out-of-pocket expenses exceed $2,490. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,620; paid at 100% after limit reached Out-of- pocket limit $3,310; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • ProvidenceXxxxxxxxxx, RI 02903XX 00000-2699 0000 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,370 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6206,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,110; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. 11/20 PL65-485514.7741 NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits.  Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. •  Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. •  Blood: First three pints of blood each year. •  Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,340 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,340. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6205,880; paid at 100% after limit reached Out-of- pocket limit $3,3102,940; paid at 100% after limit reached MPL00053 v7.20 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Nondiscrimination and Language Assistance Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 7110000. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 or 000-000-0000 (TTY/TDD: 711888-252-5051). You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 000-0000, or electronically through our member portal at xxxxxx.xxx/Xxxxxxxxxxxxxx.xxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/xxxxx://xxxxxxxxx.xxx.xxx/ocr/ portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,370 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6206,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,110; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits.  Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. •  Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. •  Blood: First three pints of blood each year. •  Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,340 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,340. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6205,880; paid at 100% after limit reached Out-of- pocket limit $3,3102,940; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • ProvidenceXxxxxxxxxx, RI 02903XX 00000-2699 0000 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,300 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6205,560; paid at 100% after limit reached Out-of- pocket limit $3,3102,780; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Nondiscrimination and Language Assistance Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 deductible. Benefits fromhigh deductible plan F will not begin until out-of-pocket expenses exceed $2,490. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,620; paid at 100% after limit reached Out-of- pocket limit $3,310; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. 01/22 PL65-642566 NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,300 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,300. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6205,560; paid at 100% after limit reached Out-of- pocket limit $3,3102,780; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • ProvidenceXxxxxxxxxx, RI 02903XX 00000-2699 0000 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Nondiscrimination and Language Assistance Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,700 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,700. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6206,940; paid at 100% after limit reached Out-of- pocket limit $3,3103,470; paid at 100% after limit reached MPL00053 v1.23 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,370 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6206,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,110; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • ProvidenceXxxxxxxxxx, RI 02903XX 00000-2699 0000 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,340 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,340. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6205,880; paid at 100% after limit reached Out-of- pocket limit $3,3102,940; paid at 100% after limit reached 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.

Basic Benefits. Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses: Part B coinsurance (generally 20% of Medicare - approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments. • Blood: First three pints of blood each year. • Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan Plan G Plan K Plan L Plan M Plan N F F* Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Basic, including 100% Part B co- insurance Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance 50% Skilled nursing facility co- insurance 75% Skilled nursing facility co- insurance Skilled nursing facility co- insurance Skilled nursing facility co- insurance Part A deductible Part A deductible Part A deductible Part A deductible Part A deductible 50% Part A deductible 75% Part A deductible 50% Part A deductible Part A deductible Part B deductible Part B deductible Part B excess (100%) Part B excess (100%) Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency Foreign travel emergency *Plan F also has an option called a high deductible plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,490 2,700 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,700. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible. Out-of- pocket limit $6,6206,940; paid at 100% after limit reached Out-of- pocket limit $3,3103,470; paid at 100% after limit reached MPL00033 v1.23 000 Xxxxxxxx Xxxxxx • Providence, RI 02903-2699 • An independent licensee of the Blue Cross and Blue Shield Association. 01/23 PL65-824890 NONDISCRIMINATION AND LANGUAGE ASSISTANCE Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us. If you need these services, contact us at 0-000-000-0000 TTY: 711. If you believe that BCBSRI has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 000 Xxxxxxxx Xxxxxx, Xxxxxxxxxx XX 00000, or by calling 0-000-000-0000 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (000) 000-0000 or electronically through our member portal at xxxxxx.xxx/Xxxxxxxx. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at xxxxx://xxxxxxxxx.xxx.xxx/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 000 Xxxxxxxxxxxx Xxxxxx, XX Xxxx 000X, XXX Xxxxxxxx Xxxxxxxxxx, X.X. 00000 800-368-1019, 000-000-0000 (TDD). Complaint forms are available at xxxx://xxx.xxx.xxx/ocr/office/file/index.html.