CAREFIRST MEDPLUS PLAN OPTIONS 2021 - MEDICARE SUPPLEMENT INSURANCE COVERAGE FOR INDIVIDUALS RESIDING IN BALTIMORE CITY, BALTIMORE COUNTY, HARFORD ...
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CareFirst MedPlus Plan
Options 2021
For individuals residing in Baltimore City, Baltimore County,
Harford County, Howard County and Anne Arundel County
MEDICARE SUPPLEMENT INSURANCE COVERAGE
Why Choose CareFirst MedPlus?
CareFirst MedPlus plans—our Medicare Supplement plans—cover most of the costs not
covered by Original Medicare. Protect yourself with a CareFirst MedPlus plan.
Power of CareFirst BlueCross BlueShield
areFirst BlueCross BlueShield—the name you’ve known and trusted for over
C
80 years—is here to help you take on retirement. CareFirst MedPlus1 plans give you
secure and stable coverage for today and whatever comes next.
Visit any doctor, any hospital
More than 90% of primary care physicians in the U.S. accept Medicare.2
You have the freedom to visit any doctor or hospital that accepts Medicare.3
Plans to meet your budget
We offer a selection of plans at competitive rates and multiple member discounts
are available on all seven MedPlus plans.
Travel stress free
Take that next adventure knowing you are covered whether traveling within the U.S.
or abroad.
Exclusive member deals
Free gym membership along with discounts on hearing aids, eyewear, meal services,
travel and more.
1
CareFirst BlueCross BlueShield and CareFirst MedPlus are affiliated entities.
2
www.kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/ accessed on July 11, 2018.
3
Standard with all Medicare Supplement plans.
800-275-3802 ■ www.carefirst.com/medigap 3
Original Medicare does not cover everything and leaves you with what is called a “coverage
gap.” Without a Medicare Supplement plan, it’s up to you to pay all the health care costs
that fall into that gap—including Medicare deductibles, copays, and even 20% of all medical
and hospital costs. CareFirst MedPlus plans fill those gaps. With seven plans to choose
from, we have a plan to meet your needs.
Power of CareFirst MedPlus
Free 24/7 nurse advice line.
CareFirst MedPlus plans are backed by
If you are unable to reach your doctor
CareFirst BlueCross BlueShield. We give
or need help after hours, FirstHelp
you stability and security that comes with:
registered nurses are available to take your
■■ National affiliation. Your card is recognized call and provide assistance.
across the country.
■■ Local company. Six walk-in offices where you
can speak with a knowledgeable representative Plans to meet your budget
who can answer any questions and discuss
We offer a selection of plans at
your health plan needs.
competitive rates and mutiple member
■■ Trust. Awarded as one discounts are available on all seven MedPlus plans.
of the most ethical
■■ Household discount. If you live with someone
companies in the world
who is enrolled in a MedPlus plan, you will
for seven years in a row.
receive a 10% discount off the monthly
premium when you enroll. The MedPlus
Visit any doctor, any hospital member living with you will also get a 10%
Each of our seven plans gives you the discount when they renew their MedPlus
freedom to visit any doctor—including coverage. (Discount applies to two actively
specialists—or hospital that accepts Medicare. No enrolled CareFirst MedPlus members.)
referrals needed. In Maryland, you have access to
■■ Discount for annual one-time payment
over 50 hospitals including:
option or automatic monthly bank
withdrawal or credit card1 option. Pay your
Large hospital systems
full annual premium in one payment and you
■■ Johns Hopkins Hospital save $24 OR sign up for monthly autopay and
■■ Anne Arundel Medical System reduce your monthly premium by $2 a month.
■■ University of Maryland Medical System
■■ LifeBridge Health
■■ MedStar Health Travel stress free
When you travel within the U.S., your
Local community hospitals CareFirst MedPlus card is accepted
■■ Mercy Medical Center anywhere Medicare is accepted. Most of our
■■ Holy Cross Hospital plans also cover emergency care for when you are
■■ Shady Grove Adventist Hospital traveling outside the U.S.
■■ Doctors Community Hospital
■■ Carroll Hospital
1
Additional fees may apply from your credit card company.
“World’s Most Ethical Companies” and “Ethisphere” names and marks are registered trademarks of Ethisphere LLC.
4
Exclusive member deals
Additional coverage
S
ilverSneakers® is a fitness program for seniors that is
options for members
included at no additional charge. MedPlus members
have access to: Why waste time shopping
multiple carriers to complete
■■ 16,000+ fitness locations1 across the country your coverage? We make
■■ Exercise classes2 led by trained instructors shopping simple. Add to your
medical coverage with the
■■ Walking tracks, tennis courts and pools1 following optional plans:
In addition to the benefits of the SilverSneakers fitness program, Dental and vision
members socialize and create a sense of community. coverage. Trips to the
Access online education on SilverSneakers.com, watch workout dentist and eye
videos on SilverSneakers On-Demand™ or download the doctor can get expensive.
SilverSneakers GO™ fitness app, for additional workout ideas. Ease the worry and the cost
with these optional plans
Exercising is just one part of staying healthy. Blue365® is a through CareFirst BlueCross
wellness discount program that helps our members stay healthy BlueShield, a private not-for-
and happy while saving money.3 Our wide range of discount profit health service plan.
offers include national brands such as: CareFirst MedPlus and
CareFirst BlueCross
BlueShield are affiliated
entities. Learn more about
these plans on page 18.
In addition to ongoing deals, there are weekly featured deals for
every aspect of your life—like fitness gear, eyewear, hearing aids,
financial services, travel discounts and more.
1
Participating locations (“PL”) are not owned or operated by Tivity Health, Inc. or its affiliates. Use of PL facilities and
amenities is limited to terms and conditions of PL basic membership. Facilities and amenities vary by PL.
2
Membership includes SilverSneakers instructor-led group fitness classes. Some locations offer members additional
classes. Classes vary by location.
3
Blue365 is sponsored by CareFirst in partnership with the Blue Cross and Blue Shield Association.
SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand and SilverSneakers GO are
trademarks of Tivity Health, Inc. © 2019 Tivity Health, Inc. All rights reserved.
SilverSneakers is a product owned by Tivity Health, Inc., an independent company that is solely responsible for their
products and provides services to CareFirst MedPlus members. Tivity Health does not sell BlueCross or BlueShield
products. SilverSneakers, Blue365 and FirstHelp are not benefits guaranteed through your Medigap insurance Policy.
They are, however, health program options made available outside of the Policy to CareFirst MedPlus members.
800-275-3802 ■ www.carefirst.com/medigap 5
Table of Contents Why Choose CareFirst MedPlus? . . . . . . . . . . . . . . . . . . . . . . . . 3 Plan Options Understanding Your Medicare Options . . . . . . . . . . . . . . . . . . 9 Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Plan Options Comparison Chart . . . . . . . . . . . . . . . . . . . . . . . 14 Health and Wellness Programs . . . . . . . . . . . . . . . . . . . . . . . . 16 Dental and Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Outline of Coverage Medicare Supplement Outline of Coverage . . . . . . . . . . . . . 23 Additional Information Open Enrollment/Guaranteed Issue Guidelines . . . . . . . . . 61 CareFirst’s Privacy Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Apply Today Three Ways to Apply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 My Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Medicare Supplement Application . . . . . . . . . . . . . . . . . . . . . 79 6
Plan Options
Understanding Your Medicare Options
Medicare, which consists of Part A (hospital) and Part B (medical) and is commonly
referred to as Original Medicare, was never designed to cover all of your health care
expenses. With Medicare alone, you could be responsible for thousands of dollars in
copays and deductibles.
Purchasing additional insurance is an important Medicare Supplement plans are:
decision. You have two main options—Medicare
Supplement, also known as Medigap, and Flexible
Medicare Advantage plans.* ■■ Select your own doctors and hospitals, as long
as they accept Medicare
Medicare Supplement plans are designed to
supplement Original Medicare by paying for the ■■ See specialists without referrals
health care costs—the gaps in coverage—that ■■ Have the same coverage when you’re traveling
Original Medicare doesn’t pay, such as the costs throughout the U.S.
below. Medicare will pay its share first and then
your Medicare Supplement plan will pay its share.
Simple
Medicare Part A ■■ Pay your monthly premium and your out-of-
pocket costs, like copays and deductibles, are
You are responsible for the deductible
limited
of $1,484 for each benefit period.
Coverage includes your hospital stays and other ■■ Know what you’re going to pay before you visit
medical facility costs including: the doctor or receive care
■■ Inpatient care in hospitals An alternative to Original Medicare and a Medicare
■■ Skilled nursing facility care Supplement plan is Medicare Advantage (MA),
also referred to as Medicare Part C. Rather
■■ Hospice care than supplementing Medicare like a Medicare
■■ Home health care Supplement plan, MA plans provide all of your Part A
(hospital) and Part B (medical) coverage. Some plans
Medicare Part B also include prescription drug (Medicare Part D)
You are responsible for the yearly coverage.
deductible of $203. After your MA plans often have restricted networks. This
deductible is met, you typically pay 20% of the means individuals in an MA plan must receive care
Medicare-approved amounts for the following: from that plan’s network of doctors and hospitals
■■ Most doctor services (including doctor services and referrals may be required to see a specialist.
you receive while you’re hospitalized) Coverage when you travel is limited to emergency
care only. While these plans may have low
■■ Outpatient therapy monthly premiums, you may be required to pay
■■ Durable medical equipment deductibles, copays and/or coinsurance when you
use services. Enrollment in an MA plan is restricted
to certain times of the year, unless you have
become eligible for Medicare for the first time.
* You cannot be enrolled in both a Medicare Supplement
plan and a Medicare Advantage plan.
800-275-3802 ■ www.carefirst.com/medigap 9
Original Medicare doesn’t cover it all
It’s important to pick a plan that works for your budget and your needs. The chart below shows the
possible out-of-pocket costs of an individual staying in the hospital a full 150 consecutive days as an
inpatient within the same benefit period.*
With Original With CareFirst
Medicare Part A
Hospital Stay MedPlus Plan G,
(Hospital) Only,
You Pay You Pay
Days 1-60 $1,484 $0
Part A deductible
Days 61-90 $11,130 $0
$371 copay x 30 days
Days 91-150** $44,520 $0
$742 copay x 60 days
A 150-day hospitalization $57,134 OR $0
would cost you: With Medicare Part A With CareFirst Plan G
**
Medicare Lifetime Reserve Days
Medicare provides coverage for at least 90 days of consecutive inpatient hospitalization after you’ve paid
your Medicare deductibles and copays. You are limited to a total of 60 additional days of hospitalization
coverage in your lifetime to be used if your initial inpatient hospitalization extends beyond 90 days. These
60 additional days are called lifetime reserve days.
With a Medicare Supplement plan, you would be covered for an additional 365 days after you use all of
your lifetime reserve days.
*A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF). The benefit
period ends when you haven’t received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you
go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient
hospital deductible for each benefit period. There’s no limit to the number of benefit periods.
Dollar amounts shown are the 2021 deductibles, copayment and coinsurance.
10 Plan OptionsPlan Options
Having Original Medicare alone could leave you with gaps in coverage and cost you
thousands of dollars in health care costs each year. Purchasing a Medicare Supplement
plan will cover the gaps in your Medicare coverage. You can pick from any of the seven
plans listed below. See the comparison chart on pages 14–15 to compare plan options.
MedPlus Plan G
Our plan with the most comprehensive
coverage and lowest out-of-pocket costs
With this plan, after you meet your $203 Part B
deductible, your medical copayments and
coinsurance are covered 100% by your plan. When
traveling in a foreign country,2 your emergency
care is covered.
MedPlus High-Deductible Plan G
Our plan with the
lowest monthly premium
After you meet your $2,370 plan deductible and
$203 Part B deductible, your hospital and medical
copayments and coinsurance are covered 100%
by your plan. When traveling in a foreign country,2
your emergency care is covered, as well as skilled
Balance Billing Protection—If you see
nursing facility care coinsurance.
a doctor who does not accept Medicare’s
MedPlus Plan N reimbursement as payment in full for
services (some doctors charge up to 15%
This plan covers your Part A deductible, but you
more than Medicare allows), Plan G and
are responsible for the $203 Medicare Part B
High-Deductible Plan G will cover these
deductible and a small copay for office and
extra charges.
emergency room visits. When traveling in a foreign
country,2 your emergency care is covered.
See detailed benefits and rates in the Outline of Coverage beginning on page 23.
1
edicare Part A and Part B deductibles are established by Medicare.
M
2
Medicare Supplement plans pay up to 80% of billed charges for Medicare-eligible expenses for emergency care
received during the first 60 consecutive days of each trip outside the United States. The plan payment is subject to a
calendar year deductible of $250 and a lifetime maximum benefit of $50,000.
800-275-3802 ■ www.carefirst.com/medigap 11MedPlus Plan M
This plan covers half of your Part A deductible— What is not covered?
you will be responsible for $742. After you meet Medicare Supplement policies are designed
your annual $203 Part B deductible and Part A to work hand-in-hand with the federal
deductible, your hospital and medical copayments Medicare program. They are not intended
and coinsurance are covered 100% by your to be classified as long-term care policies
plan. When traveling in a foreign country,2 your and do not pay for most custodial care.
emergency care is covered, as well as skilled Medicare Supplement plans do not cover
nursing facility care coinsurance. expenses for services and items excluded
from coverage under Medicare, or expenses
MedPlus Plan L for services and items that would duplicate
With this plan, you are responsible for 25% of your Medicare payments.
Part A deductible — $371. Your out-of-pocket Prescription drug coverage, or Medicare
expenses will not exceed $3,110 each year. Part D, is not included in any CareFirst
MedPlus Medicare Supplement plan.
MedPlus Plan B
This plan covers all of your $1,484 Part A
deductible. Once you meet your $203 Part B
deductible, your hospital and medical copayments Coverage is available on
and coinsurance are covered 100% by your plan. a guaranteed issue basis
MedPlus Plan A Your acceptance into one of CareFirst’s seven
Medicare Supplement plans is guaranteed with no
After you meet your annual $203 Part B deductible
review of your medical history if:
and $1,484 Part A deductible, your hospital and
medical copayments and coinsurance are covered ■■ You are within six months* of your Medicare
100% by your plan. Part B effective date (Open Enrollment)
■■ You are in a Guaranteed Issue Period (please
refer to the Additional Information section
If you were newly eligible for Medicare located in the back of this book)
prior to January 1, 2020, you may have
And—you automatically receive our lowest Level 1
additional plan options to choose from. premiums!
Call CareFirst to learn more.
The policies may have exclusions, limitations or terms under which the policy may be continued in force or discontinued.
For costs and complete details of the coverage, call your insurance agent or CareFirst MedPlus.
1
Medicare Part A and Part B deductibles are established by Medicare.
2
Medicare Supplement plans pay up to 80% of billed charges for Medicare-eligible expenses for emergency care received
during the first 60 consecutive days of each trip outside the United States. The plan payment is subject to a calendar
year deductible of $250 and a lifetime maximum benefit of $50,000.
12 Plan OptionsCoverage is available on Switching plans
an underwritten basis ■■ If you’re switching your coverage, Medicare
If you are more than six months past your will give you full credit for every dollar you’ve
Medicare Part B effective date (Open Enrollment) already spent toward your Medicare Part B
and are NOT applying during a Guaranteed deductible.
Issue Period, you will need to answer questions ■■ You may be subject to a review of your medical
regarding your medical history on the enclosed
history through medical underwriting if you are
application, MDMEDPLUSAPP (6/19). This
outside of your Open Enrollment or Guaranteed
assessment will determine your acceptance and
Issue Period.
the premium you will receive. By missing the
six-month Open Enrollment you are at risk of
We’re here to answer your questions
receiving more expensive monthly premiums.
Please refer to the Outline of Coverage in this book If you have any questions about the plans
for current pricing. described in this book, or if you’d like assistance,
just call 410-356-8123 or 800-275-3802. You’ll
You risk nothing by applying today and you’ll be receive courteous, knowledgeable assistance from
under no further obligation if you’re not satisfied one of our dedicated product consultants.
with the coverage described.
Important Notice: A Guide to Health Insurance for People with Medicare is available to
you at no charge. The guide describes the Medicare program and the health insurance
available to those with Medicare. If you are interested in receiving this free guide, visit
www.medicare.gov/pubs/pdf/02110-medicare-medigap-guide.pdf to download a copy or
call us at 410-356-8123 or 800-275-3802 to receive a printed guide.
* In Maryland, if you are under the age of 65 and disabled, your Open Enrollment Period will begin on the date you are
notified by Medicare of your enrollment in Part B.
800-275-3802 ■ www.carefirst.com/medigap 13Plan Options Comparison Chart
What You Pay with Original Medicare
versus CareFirst MedPlus Plans
With With MedPlus
MedPlus High-Deductible
With Original With With
Plan F Plan F*
Medicare MedPlus MedPlus
You Pay You Pay
alone, Plan A Plan B
You Pay You Pay You Pay Only applicants who are eligible for
Medicare before January 1, 2020 may
purchase High-Deductible Plan F
Hospital Services (Part A)
Inpatient hospital $0 after plan
$1,484 $1,484 $0 $0
deductible deductible
$0 after plan
Hospital days 61-90 $371/day $0 $0 $0
deductible
Hospital days 91-150 $0 after plan
$742/day $0 $0 $0
(lifetime reserve) deductible
365 days after hospital $0 after plan
All costs $0 $0 $0
benefits stop deductible
Skilled nursing facility $0 after plan
$185.50/day $185.50/day $185.50/day $0
days 21-100 deductible
Medical Expenses (Part B)
Medical expense $0 after plan
$203 $203 $203 $0
deductible deductible
Medical expenses after $0 after plan
20% 0% 0% 0%
deductible deductible
Excess charges above
$0 after plan
Medicare-approved 100% 100% 100% $0
deductible
amounts (balance billing)
Other Expenses
Foreign country
$250 deductible
emergency care $250
after plan
(beginning the first 60 100% 100% 100% deductible,
deductible, then
days of each trip outside then 20%***
20%***
the USA)
14 Plan OptionsComparison
What You Pay with Original Medicare
versus CareFirst MedPlus Plans
With With MedPlus With With With
MedPlus High-Deductible MedPlus MedPlus MedPlus
Plan G Plan G* Plan L** Plan M Plan N
You Pay You Pay You Pay You Pay You Pay
Hospital Services (Part A)
Inpatient hospital $0 after plan
$0 $371 $742 $0
deductible deductible
$0 after plan
Hospital days 61-90 $0 $0 $0 $0
deductible
Hospital days 91-150 $0 after plan
$0 $0 $0 $0
(lifetime reserve) deductible
365 days after hospital $0 after plan
$0 $0 $0 $0
benefits stop deductible
Skilled nursing facility $0 after plan Up to
$0 $0 $0
days 21-100 deductible $46.38/day
Medical Expenses (Part B)
Medical expense $0 after plan
$203 $203 $203 $203
deductible deductible
Office visit—
Medical expenses after $0 after plan up to $20
0% 5% 0%
deductible deductible ER visit—up
to $50
Excess charges above
$0 after plan
Medicare-approved 0% 100% 100% 100%
deductible
amounts (balance billing)
Other Expenses
Foreign country
$250 deductible,
emergency care $250 $250 $250
after plan
(beginning the first deductible, 100% deductible, deductible,
deductible, then
60 days of each trip then 20%*** then 20%*** then 20%***
20%***
outside the USA)
Dollar amounts shown are the 2021 deductibles, copayment and coinsurance.
*With High-Deductible Plan G, there is an annual plan deductible of $2,370. After you meet the deductible, you pay $0.
**With Plan L, there is an out-of-pocket limit of $3,110. After you meet the out-of-pocket limit, you pay $0.
***Up to $50,000 lifetime maximum.
800-275-3802 ■ www.carefirst.com/medigap 15Health and Wellness
Programs
Looking to get active, have fun
and make friends?
Through SilverSneakers,1 CareFirst MedPlus gives
our members a way to get healthy and have
fun—at no additional cost. SilverSneakers works
to improve your overall well-being, fitness, and
strength and gives you the chance to socialize,
make new friends and connect with your
community.
CareFirst MedPlus and SilverSneakers offer you:
■■ Membership at more than 16,000 gyms and
fitness locations2 in the United States
■■ Access to fitness equipment2
■■ Specially-designed, signature exercise classes
for all fitness levels3
■■ Pools, tennis courts and walking tracks2
Can’t get to a fitness location? SilverSneakers
also offers an at-home option for members
who want to start working out, but can’t get
to a fitness location.
Enrolling couldn’t be easier. You’ll be
automatically enrolled in SilverSneakers once
you become a CareFirst MedPlus member. Your
SilverSneakers welcome postcard will be mailed
to you.
1
S ilverSneakers is a product owned by Tivity Health, Inc., an independent company that is solely responsible for their
products and provides services to CareFirst MedPlus members. SilverSneakers is not a benefit guaranteed through your
Medicare Supplement insurance Policy. It is, however, a health program option made available outside of the Policy to
CareFirst MedPlus members.
2
Participating locations (“PL”) are not owned or operated by Tivity Health, Inc. or its affiliates. Use of PL facilities and
amenities is limited to terms and conditions of PL basic membership. Facilities and amenities vary by PL.
3
Membership includes SilverSneakers instructor-led group fitness classes. Some locations offer members additional
classes. Classes vary by location.
SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand™ and SilverSneakers GO™ are
trademarks of Tivity Health, Inc. ©2019 Tivity Health, Inc. All rights reserved.
16 Plan OptionsInteractive tools and resources Exclusive member discounts
Visit www.carefirst.com/livinghealthy to Blue365 is an exciting program that offers
access health tools that are informative and easy exclusive health, wellness and personal deals that
to use. will keep you healthy and happy, every day of the
year. Blue365 delivers great discounts from top
■■ Personalized features that let you record your
national and local retailers on:
health goals, reminders and medical history
on our secure server ■■ Fitness gear
■■ Healthy cooking videos and recipes divided by ■■ Healthy eating
category, including low sodium, heart-healthy
■■ Family activities
and diabetes-friendly options
■■ Hotel and travel discounts
■■ A library of articles about diseases,
health conditions, wellness tips, tests and ■■ Eldercare assistance and much more
procedures
Visit www.carefirst.com/wellnessdiscounts to
■■ A multimedia section with videos, podcasts learn more.
and tutorials about a variety of health topics
■■ Preventive guidelines
■■ Information on nutrition, smoking cessation,
stress, weight management and more
Save 30 to 60% on hearing aids from
TruHearing along with other health
and wellness discounts.
We’re here to answer your questions.
If you have any questions about the plans described in this book, you can speak to one of our
dedicated product consultants at 410-356-8123 or 800-275-3802.
The Blue365 program is not offered as an inducement to purchase a policy of insurance from CareFirst BlueCross
BlueShield. CareFirst BlueCross BlueShield does not underwrite this program because it is not an insurance product.
No benefits are paid by CareFirst BlueCross BlueShield under this program. The discount program listed above is not
guaranteed by CareFirst BlueCross BlueShield or CareFirst MedPlus and may be discontinued at any time.
800-275-3802 ■ www.carefirst.com/medigap 17Dental and Vision
Dental coverage (optional)
Your smile says a lot about your overall health. That’s why good
dental care is so important. Complete your health coverage with
a dental plan from CareFirst BlueCross BlueShield or The Dental
Network. We offer three options:*
All dental plans are
Individual Select Dental HMO offers lower, predictable
guaranteed acceptance
■■
copayments for routine and major dental services such as
preventive and diagnostic care, surgical extractions, root canal and require no claim
therapy and orthodontic treatment. Select from a network of more forms when you stay
than 600 participating providers. There is no deductible to meet. in-network. If you
■■ Individual Select Preferred Dental offers 100% coverage for have questions or
preventive and diagnostic dental care as well as a network of more would like to apply
than 5,000 participating providers. There is no deductible to meet. for dental coverage,
■■ BlueDental Preferred offers the largest network with more than please contact one of
5,000 providers in Maryland, Washington, D.C. and Virginia and our dental product
access to 123,000 dental providers across the country. See any
consultants at
doctor—no referral needed. Enjoy no charge oral exams, cleanings
and X-rays when you visit an in-network provider. BlueDental 855-503-4862.
Preferred has no benefit waiting periods.
Note: The dental and vision plans referenced are not part of any MedPlus Medicare Supplement
policy. To receive coverage for dental and/or vision services, you must apply separately for these
plans. You do not need to be enrolled in a CareFirst medical plan to purchase a dental plan;
however, you do need to be enrolled in a CareFirst medical plan to purchase a vision plan. The plans
are not offered as an inducement to purchase a Medicare Supplement policy from CareFirst.
*Individual Select Dental HMO is underwritten by The Dental Network; Individual Select Preferred Dental is underwritten
by Group Hospitalization and Medical Services, Inc.; BlueDental Preferred is underwritten by CareFirst of Maryland,
Inc. or Group Hospitalization and Medical Services, Inc.; CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
18 Plan OptionsInterested in learning more about dental and vision coverage?
Give us a call at 855-503-4862—or complete and mail this Free Information Request Card.
BlueVision℠ (optional)
For just $2 a month, protect your eyes with a
separate vision plan from CareFirst BlueCross
BlueShield, administered by Davis Vision, Inc.*
Receive an annual eye exam with dilation
at participating providers for a $10 copay Mail this card for free information
at the time of service, plus discounts** of
YES, please rush me more information about the
approximately 30% on eyeglass frames and
plan(s) that I’ve checked below. I understand this
lenses or contact lenses from certain providers.
information is free and I am under no obligation.
Our vision plan is guaranteed acceptance and
requires no claim forms when you stay in- Dental Plan Options
network. If you have questions or would like to Individual Select Dental HMO
apply for vision coverage, please contact one of
BlueDental Preferred
our product consultants at 410-356-8123
or 800-275-3802. Individual Select Preferred Dental
Locate a participating provider at Vision Option
www.carefirst.comor call Davis Vision at BlueVision℠
800-783-5602.
O65ANC2017
NAME:
ADDRESS:
*Davis Vision is an independent company that provides
administrative services for vision care to CareFirst
members. Davis Vision is solely responsible for the
services it provides.
CITY:
**Some providers in Maryland and Virginia may no
longer provide these discounts.
STATE: ZIP:
800-275-3802 ■ www.carefirst.com/medigap 1920
ROUTE TO: MAIL STOP OM2-345
Plan OptionsOutline of Coverage
Outline of Coverage
Medicare Supplement Outline of Coverage Includes detailed benefit and rate information
Medicare Supplement Plans A, B, F, High-Deductible F,
G, High-Deductible G, L, M and N
For individuals residing in Baltimore City, Baltimore County,
Harford County, Howard County and Anne Arundel County
The Medicare deductibles and copays listed in this Outline of Coverage reflect 2021 Medicare costs and
are subject to change each year as we receive updated figures from the federal government. New Medicare
deductibles and copays go into effect on January 1 of each year. Offered by First Care, Inc.*, d/b/a CareFirst MedPlus,
10455 Mill Run Circle, Owings Mills, Maryland 21117-5559.
*An independent licensee of the Blue Cross and Blue Shield Association
MDBMSUPPOOC (6/19)CareFirst MedPlus
Medicare Supplement Outline of Coverage
■ This chart shows the benefits included in each of Basic Benefits:
the standard Medicare Supplement plans. Hospitalization: Part A coinsurance plus coverage
■ Every company must make Plan A available. for 365 additional days after Medicare benefits end.
■ Some plans may not be available in your state. Medical Expenses: Part B coinsurance (generally
■ CareFirst MedPlus offers plans A, B, F, 20% of Medicare-approved expenses) or
High-Deductible F, G, High-Deductible G, L, M copayments for hospital outpatient services. Plans
and N as shaded below. K, L and N require insureds to pay a portion of
■ Only applicants who are eligible for Medicare Part B coinsurance or copayments.
before January 1, 2020 may purchase Plans F Blood: First three pints of blood each year.
and High-Deductible Plan F.
Hospice: Part A coinsurance.
Medicare
Plans available to all applicants eligible before
Benefits 1/1/2020 only
A B D G1 K L M N C F1
Medicare Part A coinsurance ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
and hospital coverage (up to
an additional 365 days after
Medicare benefits are used up)
Medicare Part B coinsurance or ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔
copayment copays
apply3
Blood (first three pints) ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔
Part A hospice care coinsurance ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔
or copayment
Skilled nursing facility coinsurance ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔
Medicare Part A deductible ✔ ✔ ✔ ✔ 50% 75% 50% ✔ ✔ ✔
Medicare Part B deductible ✔ ✔
Medicare Part B excess charges ✔ ✔
Foreign travel emergency (up to ✔ ✔ ✔ ✔ ✔ ✔
plan limits)
Out-of-pocket limit in 20212 $6,2202 $3,1102
Note: ✔ means 100% of the benefit is paid.
1
Plans F and G also have a high deductible option which require first paying a plan deductible of $2,370 before
the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the
calendar year. High deductible Plan G does not cover the Medicare Part B deductible. However, high deductible Plans
F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.
2
Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.
3
Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a
$50 copayment for emergency room visits that do not result in an inpatient admission.
24CareFirst MedPlus
Medicare Supplement Outline of Coverage
Premium information Right to return policy
CareFirst MedPlus can only raise your premiums if If you find that you are not satisfied with your
we raise the premiums for all policies like yours in policy, you may return it to:
your geographical region of your state.
First Care, Inc.
Under Medicare supplement policies A, B, F, d/b/a CareFirst MedPlus
High-Deductible F, N, G, High-Deductible G, Individual Market Division
L and M, which use attained age rating, premiums 10800 Red Run Boulevard, RRE-375
automatically increase as you get older. You can Owings Mills, MD 21117
expect your premiums to increase each year due
If you send the policy back to us within 30 days
to changes in age. We reserve the right to adjust
after you receive it, we will treat the policy as
premiums on your renewal.
if it had never been issued and return all of
The rate increase will be effective on the first of the your payments.
policy renewal month. The policy renewal month
means the month in which the policy becomes Policy replacement
effective and each subsequent anniversary of that If you are replacing another health insurance
month. If the change from one age to another policy, do NOT cancel it until you have actually
occurs prior to the policy renewal month, the rate received your new policy and are sure you want to
increase will not be effective until the first of the keep it.
policy renewal month. You will be notified of any
rate increase at least 45 days prior to the date that Notice
a premium increase becomes effective.
This policy may not fully cover all of your medical
Only applicants who are eligible for Medicare costs. Neither CareFirst MedPlus nor its agents are
before January 1, 2020 may purchase Plans F connected with Medicare. This outline of coverage
and High-Deductible Plan F. does not give all the details of Medicare coverage.
Contact your local Social Security Office or consult
Read your policy very carefully Medicare and You for more details.
This is only an outline describing your policy’s
most important features. The policy is your Complete answers are very important
insurance contract. You must read the policy itself When you fill out the application for your new
to understand all of the rights and duties of both policy, be sure to answer truthfully and completely
you and your insurance company. all questions about your medical and health
history. The company may cancel your policy and
refuse to pay any claims if you leave out or falsify
important medical information.
Review the application carefully before you sign it.
Be certain that all information has been properly
recorded.
800-275-3802 ■ www.carefirst.com/medigap 25CareFirst MedPlus: Level 1, Female Rates
If you are applying within six months of your Medicare Part B effective date (Open Enrollment) or during
a Guaranteed Issue Period, the Level 1 Rate applies and is dependent on the plan you select, your age
and gender. You are not required to answer any health or tobacco use questions found in Section 4 of the
application. Therefore, tobacco use and health screening questions will not be used in determining your rate.
If you are applying between seven months and 10 years past your Medicare Part B effective date, then
your Level 1 Rate eligibility will depend on tobacco status and health evaluation.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off
your annual rate if you elect automated payment via bank withdrawal or credit card payment; or
elect the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $741.15 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $635.52 $176.49 $158.23 $31.29 $126.93 $193.01 $140.84 $203.44 $32.16
66 $667.30 $185.31 $166.14 $32.86 $133.27 $202.66 $147.88 $213.61 $33.77
67 $700.66 $194.58 $174.45 $34.50 $139.94 $212.79 $155.28 $224.29 $35.46
68 $735.69 $204.31 $183.17 $36.23 $146.93 $223.43 $163.04 $235.51 $37.23
69 $772.48 $214.52 $192.33 $38.04 $154.28 $234.60 $171.19 $247.28 $39.10
70 $803.38 $223.10 $200.02 $39.56 $160.45 $243.98 $178.04 $257.17 $40.66
71 $835.51 $232.03 $208.02 $41.14 $166.87 $253.74 $185.16 $267.46 $42.29
72 $868.93 $241.31 $216.34 $42.79 $173.54 $263.89 $192.57 $278.16 $43.98
73 $903.69 $250.96 $225.00 $44.50 $180.49 $274.45 $200.27 $289.29 $45.74
74 $939.84 $261.00 $234.00 $46.28 $187.70 $285.43 $208.28 $300.86 $47.57
75 $974.61 $270.66 $242.66 $47.99 $194.65 $295.99 $215.99 $311.99 $49.33
76 $1,010.67 $280.67 $251.63 $49.77 $201.85 $306.94 $223.98 $323.53 $51.15
77 $1,048.07 $291.05 $260.94 $51.61 $209.32 $318.29 $232.27 $335.50 $53.04
78 $1,086.85 $301.82 $270.60 $53.52 $217.06 $330.07 $240.86 $347.92 $55.01
79 $1,127.06 $312.99 $280.61 $55.50 $225.10 $342.28 $249.78 $360.79 $57.04
80 $1,146.65 $318.43 $285.49 $56.46 $229.01 $348.23 $254.12 $367.06 $58.03
81 $1,166.60 $323.97 $290.46 $57.45 $232.99 $354.29 $258.54 $373.45 $59.04
82 $1,186.85 $329.59 $295.50 $58.44 $237.04 $360.44 $263.03 $379.93 $60.07
83 $1,207.31 $335.28 $300.59 $59.45 $241.12 $366.66 $267.56 $386.48 $61.10
84 $1,228.00 $341.02 $305.74 $60.47 $245.26 $372.94 $272.15 $393.10 $62.15
85 $1,249.12 $346.89 $311.00 $61.51 $249.47 $379.35 $276.83 $399.86 $63.22
86 $1,264.11 $351.05 $314.73 $62.25 $252.47 $383.90 $280.15 $404.66 $63.98
87 $1,279.31 $355.27 $318.52 $62.99 $255.50 $388.52 $283.52 $409.53 $64.75
88 $1,294.66 $359.53 $322.34 $63.75 $258.57 $393.18 $286.92 $414.44 $65.52
89 $1,310.23 $363.86 $326.22 $64.52 $261.68 $397.91 $290.37 $419.42 $66.31
90 & $1,325.87 $368.20 $330.11 $65.29 $264.80 $402.66 $293.83 $424.43 $67.10
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for individuals
residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
26CareFirst MedPlus: Level 1, Male Rates
If you are applying within six months of your Medicare Part B effective date (Open Enrollment) or during
a Guaranteed Issue Period, the Level 1 Rate applies and is dependent on the plan you select, your age
and gender. You are not required to answer any health or tobacco use questions found in Section 4 of the
application. Therefore, tobacco use and health screening questions will not be used in determining your rate.
If you are applying between seven months and 10 years past your Medicare Part B effective date, then
your Level 1 Rate eligibility will depend on tobacco status and health evaluation.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your
annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect
the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $766.69 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $676.94 $187.99 $168.54 $33.33 $135.20 $205.58 $150.02 $216.70 $34.26
66 $710.79 $197.39 $176.97 $35.00 $141.96 $215.86 $157.52 $227.53 $35.97
67 $746.33 $207.26 $185.82 $36.75 $149.06 $226.66 $165.40 $238.91 $37.77
68 $783.65 $217.62 $195.11 $38.59 $156.51 $237.99 $173.67 $250.86 $39.66
69 $822.83 $228.50 $204.86 $40.52 $164.34 $249.89 $182.35 $263.40 $41.64
70 $855.74 $237.64 $213.06 $42.14 $170.91 $259.89 $189.65 $273.94 $43.31
71 $889.97 $247.15 $221.58 $43.82 $177.74 $270.28 $197.23 $284.89 $45.04
72 $925.57 $257.04 $230.45 $45.58 $184.85 $281.09 $205.12 $296.29 $46.84
73 $962.59 $267.32 $239.66 $47.40 $192.25 $292.34 $213.33 $308.14 $48.72
74 $1,001.10 $278.01 $249.25 $49.30 $199.94 $304.03 $221.86 $320.47 $50.67
75 $1,038.14 $288.30 $258.47 $51.12 $207.34 $315.28 $230.07 $332.32 $52.54
76 $1,076.55 $298.96 $268.04 $53.01 $215.01 $326.94 $238.58 $344.62 $54.49
77 $1,116.38 $310.03 $277.95 $54.97 $222.96 $339.04 $247.41 $357.37 $56.50
78 $1,157.69 $321.50 $288.24 $57.01 $231.21 $351.58 $256.56 $370.59 $58.59
79 $1,200.52 $333.39 $298.90 $59.12 $239.77 $364.59 $266.06 $384.30 $60.76
80 $1,230.56 $341.73 $306.38 $60.59 $245.77 $373.72 $272.71 $393.92 $62.28
81 $1,261.36 $350.29 $314.05 $62.11 $251.92 $383.07 $279.54 $403.78 $63.84
82 $1,292.91 $359.05 $321.90 $63.66 $258.22 $392.65 $286.53 $413.88 $65.44
83 $1,325.21 $368.02 $329.95 $65.26 $264.67 $402.46 $293.69 $424.22 $67.07
84 $1,358.34 $377.22 $338.19 $66.89 $271.29 $412.52 $301.03 $434.82 $68.75
85 $1,392.28 $386.64 $346.65 $68.56 $278.07 $422.83 $308.55 $445.69 $70.46
86 $1,408.98 $391.28 $350.80 $69.38 $281.40 $427.90 $312.25 $451.04 $71.31
87 $1,425.88 $395.98 $355.01 $70.21 $284.78 $433.04 $316.00 $456.45 $72.17
88 $1,442.99 $400.73 $359.27 $71.05 $288.19 $438.23 $319.79 $461.92 $73.03
89 $1,460.31 $405.54 $363.58 $71.91 $291.65 $443.49 $323.63 $467.47 $73.91
90 & $1,477.83 $410.40 $367.94 $72.77 $295.15 $448.81 $327.51 $473.07 $74.79
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for
individuals residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
800-275-3802 ■ www.carefirst.com/medigap 27CareFirst MedPlus: Level 2, Non-Tobacco Female Rates
If you are applying more than six months past your Medicare Part B effective date, and are NOT applying
during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending
on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based
on the plan you select, your age, gender and tobacco use.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your
annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect
the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $815.26 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $794.40 $220.61 $197.79 $39.12 $158.66 $241.26 $176.05 $254.30 $40.21
66 $820.77 $227.93 $204.35 $40.42 $163.92 $249.27 $181.90 $262.74 $41.54
67 $847.80 $235.44 $211.08 $41.75 $169.32 $257.47 $187.89 $271.39 $42.91
68 $875.48 $243.12 $217.97 $43.11 $174.85 $265.88 $194.02 $280.25 $44.31
69 $903.80 $250.99 $225.03 $44.50 $180.51 $274.48 $200.30 $289.32 $45.74
70 $931.92 $258.80 $232.03 $45.89 $186.12 $283.02 $206.53 $298.32 $47.17
71 $960.84 $266.83 $239.23 $47.31 $191.90 $291.80 $212.94 $307.58 $48.63
72 $990.58 $275.09 $246.63 $48.78 $197.84 $300.84 $219.53 $317.10 $50.13
73 $1,021.17 $283.59 $254.25 $50.28 $203.95 $310.13 $226.31 $326.89 $51.68
74 $1,052.62 $292.32 $262.08 $51.83 $210.23 $319.68 $233.28 $336.96 $53.27
75 $1,072.07 $297.72 $266.92 $52.79 $214.11 $325.58 $237.59 $343.19 $54.26
76 $1,111.74 $308.74 $276.80 $54.74 $222.04 $337.63 $246.38 $355.88 $56.27
77 $1,152.87 $320.16 $287.04 $56.77 $230.25 $350.12 $255.50 $369.05 $58.35
78 $1,195.53 $332.01 $297.66 $58.87 $238.77 $363.08 $264.95 $382.71 $60.51
79 $1,239.77 $344.29 $308.67 $61.05 $247.61 $376.51 $274.75 $396.87 $62.75
80 $1,261.31 $350.27 $314.04 $62.11 $251.91 $383.06 $279.53 $403.77 $63.84
81 $1,283.26 $356.37 $319.50 $63.19 $256.29 $389.72 $284.39 $410.79 $64.95
82 $1,305.53 $362.55 $325.05 $64.29 $260.74 $396.49 $289.33 $417.92 $66.07
83 $1,328.04 $368.81 $330.65 $65.39 $265.24 $403.32 $294.32 $425.13 $67.21
84 $1,350.80 $375.12 $336.32 $66.52 $269.78 $410.23 $299.36 $432.41 $68.37
85 $1,374.03 $381.58 $342.10 $67.66 $274.42 $417.29 $304.51 $439.85 $69.54
86 $1,390.52 $386.15 $346.21 $68.47 $277.71 $422.29 $308.16 $445.13 $70.38
87 $1,407.24 $390.80 $350.37 $69.29 $281.05 $427.37 $311.87 $450.48 $71.22
88 $1,424.12 $395.49 $354.57 $70.13 $284.43 $432.50 $315.61 $455.88 $72.08
89 $1,441.25 $400.24 $358.84 $70.97 $287.85 $437.70 $319.40 $461.37 $72.94
90 & $1,458.45 $405.02 $363.12 $71.82 $291.28 $442.93 $323.22 $466.87 $73.81
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for
individuals residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
28CareFirst MedPlus: Level 2, Non-Tobacco Male Rates
If you are applying more than six months past your Medicare Part B effective date, and are NOT applying
during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending
on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based
on the plan you select, your age, gender and tobacco use.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your
annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect
the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $843.35 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $846.18 $234.99 $210.68 $41.67 $169.00 $256.98 $187.53 $270.87 $42.83
66 $874.27 $242.79 $217.67 $43.05 $174.61 $265.51 $193.75 $279.87 $44.25
67 $903.06 $250.78 $224.84 $44.47 $180.36 $274.26 $200.13 $289.08 $45.70
68 $932.54 $258.97 $232.18 $45.92 $186.25 $283.21 $206.67 $298.52 $47.20
69 $962.71 $267.35 $239.69 $47.41 $192.27 $292.37 $213.35 $308.18 $48.72
70 $992.66 $275.67 $247.15 $48.88 $198.25 $301.47 $219.99 $317.77 $50.24
71 $1,023.47 $284.22 $254.82 $50.40 $204.41 $310.82 $226.82 $327.63 $51.80
72 $1,055.15 $293.02 $262.71 $51.96 $210.73 $320.44 $233.84 $337.77 $53.40
73 $1,087.73 $302.07 $270.82 $53.56 $217.24 $330.34 $241.06 $348.20 $55.05
74 $1,121.23 $311.37 $279.16 $55.21 $223.93 $340.51 $248.48 $358.92 $56.75
75 $1,141.95 $317.13 $284.32 $56.23 $228.07 $346.81 $253.08 $365.56 $57.80
76 $1,184.20 $328.86 $294.84 $58.31 $236.51 $359.64 $262.44 $379.08 $59.93
77 $1,228.02 $341.03 $305.75 $60.47 $245.26 $372.94 $272.15 $393.11 $62.15
78 $1,273.45 $353.65 $317.06 $62.71 $254.33 $386.74 $282.22 $407.65 $64.45
79 $1,320.57 $366.73 $328.79 $65.03 $263.74 $401.05 $292.66 $422.74 $66.84
80 $1,353.62 $375.91 $337.02 $66.65 $270.34 $411.09 $299.99 $433.31 $68.51
81 $1,387.50 $385.32 $345.45 $68.32 $277.11 $421.38 $307.49 $444.16 $70.22
82 $1,422.20 $394.95 $354.09 $70.03 $284.04 $431.92 $315.18 $455.27 $71.98
83 $1,457.73 $404.82 $362.94 $71.78 $291.14 $442.71 $323.06 $466.64 $73.78
84 $1,494.17 $414.94 $372.01 $73.57 $298.42 $453.77 $331.13 $478.31 $75.62
85 $1,531.51 $425.31 $381.31 $75.41 $305.87 $465.11 $339.41 $490.26 $77.51
86 $1,549.88 $430.41 $385.88 $76.32 $309.54 $470.69 $343.48 $496.14 $78.44
87 $1,568.47 $435.57 $390.51 $77.23 $313.25 $476.34 $347.60 $502.09 $79.38
88 $1,587.29 $440.80 $395.20 $78.16 $317.01 $482.05 $351.77 $508.12 $80.33
89 $1,606.34 $446.09 $399.94 $79.10 $320.82 $487.84 $355.99 $514.21 $81.30
90 & $1,625.61 $451.44 $404.74 $80.05 $324.67 $493.69 $360.26 $520.38 $82.27
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for
individuals residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
800-275-3802 ■ www.carefirst.com/medigap 29CareFirst MedPlus: Level 2, Tobacco Female Rates
If you are applying more than six months past your Medicare Part B effective date, and are NOT applying
during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending
on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based
on the plan you select, your age, gender and tobacco use.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your
annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect
the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $1,018.85 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $992.77 $275.69 $247.17 $48.90 $198.29 $301.50 $220.01 $317.79 $50.25
66 $1,025.73 $284.84 $255.38 $50.52 $204.87 $311.51 $227.32 $328.34 $51.92
67 $1,059.51 $294.22 $263.79 $52.18 $211.62 $321.76 $234.80 $339.15 $53.63
68 $1,094.10 $303.83 $272.40 $53.89 $218.53 $332.27 $242.46 $350.23 $55.38
69 $1,129.49 $313.66 $281.21 $55.63 $225.60 $343.02 $250.31 $361.56 $57.17
70 $1,164.63 $323.42 $289.96 $57.36 $232.61 $353.69 $258.10 $372.80 $58.95
71 $1,200.78 $333.45 $298.96 $59.14 $239.83 $364.67 $266.11 $384.37 $60.78
72 $1,237.95 $343.78 $308.21 $60.97 $247.26 $375.95 $274.34 $396.27 $62.66
73 $1,276.17 $354.39 $317.73 $62.85 $254.89 $387.56 $282.82 $408.51 $64.60
74 $1,315.47 $365.31 $327.52 $64.79 $262.74 $399.50 $291.52 $421.09 $66.59
75 $1,339.79 $372.06 $333.57 $65.99 $267.60 $406.88 $296.91 $428.87 $67.82
76 $1,389.36 $385.82 $345.91 $68.43 $277.50 $421.94 $307.90 $444.74 $70.33
77 $1,440.77 $400.10 $358.71 $70.96 $287.77 $437.55 $319.29 $461.20 $72.93
78 $1,494.07 $414.90 $371.98 $73.59 $298.41 $453.74 $331.10 $478.26 $75.63
79 $1,549.35 $430.25 $385.75 $76.31 $309.45 $470.53 $343.36 $495.96 $78.43
80 $1,576.28 $437.73 $392.45 $77.64 $314.83 $478.70 $349.32 $504.58 $79.79
81 $1,603.71 $445.35 $399.28 $78.99 $320.31 $487.03 $355.40 $513.36 $81.18
82 $1,631.54 $453.08 $406.21 $80.36 $325.87 $495.49 $361.57 $522.27 $82.59
83 $1,659.68 $460.89 $413.21 $81.74 $331.49 $504.03 $367.80 $531.27 $84.01
84 $1,688.11 $468.79 $420.29 $83.14 $337.17 $512.67 $374.11 $540.37 $85.45
85 $1,717.15 $476.85 $427.52 $84.57 $342.97 $521.48 $380.54 $549.67 $86.92
86 $1,737.75 $482.57 $432.65 $85.59 $347.08 $527.74 $385.11 $556.26 $87.96
87 $1,758.65 $488.37 $437.85 $86.62 $351.26 $534.09 $389.74 $562.95 $89.02
88 $1,779.75 $494.23 $443.11 $87.66 $355.47 $540.49 $394.41 $569.71 $90.09
89 $1,801.15 $500.18 $448.44 $88.71 $359.75 $546.99 $399.16 $576.56 $91.17
90 & $1,822.65 $506.15 $453.79 $89.77 $364.04 $553.52 $403.92 $583.44 $92.26
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for
individuals residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
30CareFirst MedPlus: Level 2, Tobacco Male Rates
If you are applying more than six months past your Medicare Part B effective date, and are NOT applying
during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending
on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based
on the plan you select, your age, gender and tobacco use.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your
annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect
the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $1,053.95 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $1,057.48 $293.66 $263.28 $52.08 $211.21 $321.15 $234.35 $338.51 $53.53
66 $1,092.59 $303.41 $272.02 $53.81 $218.22 $331.81 $242.13 $349.74 $55.31
67 $1,128.57 $313.40 $280.98 $55.58 $225.41 $342.74 $250.10 $361.26 $57.13
68 $1,165.41 $323.63 $290.15 $57.40 $232.77 $353.92 $258.27 $373.05 $58.99
69 $1,203.11 $334.10 $299.54 $59.26 $240.30 $365.37 $266.62 $385.12 $60.90
70 $1,240.54 $344.50 $308.86 $61.10 $247.78 $376.74 $274.92 $397.10 $62.80
71 $1,279.04 $355.19 $318.45 $63.00 $255.46 $388.43 $283.45 $409.43 $64.74
72 $1,318.64 $366.18 $328.30 $64.95 $263.37 $400.46 $292.23 $422.10 $66.75
73 $1,359.35 $377.49 $338.44 $66.95 $271.51 $412.82 $301.25 $435.14 $68.81
74 $1,401.22 $389.12 $348.86 $69.01 $279.87 $425.54 $310.53 $448.54 $70.93
75 $1,427.11 $396.31 $355.31 $70.29 $285.04 $433.40 $316.27 $456.83 $72.24
76 $1,479.92 $410.97 $368.46 $72.89 $295.59 $449.44 $327.97 $473.73 $74.91
77 $1,534.67 $426.18 $382.09 $75.59 $306.52 $466.07 $340.10 $491.26 $77.68
78 $1,591.46 $441.94 $396.23 $78.38 $317.86 $483.31 $352.69 $509.43 $80.56
79 $1,650.34 $458.30 $410.89 $81.28 $329.62 $501.19 $365.74 $528.28 $83.54
80 $1,691.64 $469.77 $421.17 $83.32 $337.87 $513.74 $374.89 $541.50 $85.63
81 $1,733.98 $481.52 $431.71 $85.40 $346.33 $526.59 $384.27 $555.05 $87.77
82 $1,777.35 $493.57 $442.51 $87.54 $354.99 $539.76 $393.88 $568.94 $89.97
83 $1,821.75 $505.90 $453.56 $89.73 $363.86 $553.25 $403.72 $583.15 $92.22
84 $1,867.29 $518.54 $464.90 $91.97 $372.96 $567.08 $413.81 $597.73 $94.52
85 $1,913.95 $531.50 $476.52 $94.27 $382.28 $581.25 $424.15 $612.66 $96.88
86 $1,936.90 $537.88 $482.23 $95.40 $386.86 $588.22 $429.24 $620.01 $98.04
87 $1,960.14 $544.33 $488.02 $96.54 $391.50 $595.28 $434.39 $627.45 $99.22
88 $1,983.66 $550.86 $493.88 $97.70 $396.20 $602.42 $439.60 $634.98 $100.41
89 $2,007.46 $557.47 $499.80 $98.87 $400.95 $609.65 $444.88 $642.60 $101.62
90 & $2,031.55 $564.16 $505.80 $100.06 $405.76 $616.96 $450.22 $650.31 $102.84
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for
individuals residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
800-275-3802 ■ www.carefirst.com/medigap 31CareFirst MedPlus: Level 3, Non-Tobacco Female Rates
If you are applying more than six months past your Medicare Part B effective date, and are NOT applying
during a Guaranteed Issue Period, your medical history will be reviewed (medical underwriting). Depending
on the review of your medical history, you may receive a Level 2 or Level 3 Rate. Your rate also will be based
on the plan you select, your age, gender and tobacco use.
You can receive a 10% discount if you reside with someone who is also actively enrolled in a
CareFirst MedPlus plan. You can also receive a discount of $2 off your monthly rate or $24 off your
annual rate if you elect automated payment via bank withdrawal or credit card payment; or elect
the annual payment option. See Section 6 of your application.
Monthly Premium Rates Effective January 1, 2021
Medicare eligible
Plans available to all applicants
before 1/1/20 only
High-Ded High-Ded
Plan A Plan B Plan G Plan L Plan M Plan N Plan F
G F
Under $1,185.84 N/A N/A N/A N/A N/A N/A N/A N/A
65
65 $1,271.04 $352.98 $316.46 $62.59 $253.85 $386.01 $281.68 $406.88 $64.33
66 $1,321.25 $366.92 $328.96 $65.06 $263.88 $401.26 $292.81 $422.95 $66.87
67 $1,366.29 $379.43 $340.17 $67.28 $272.88 $414.94 $302.79 $437.37 $69.15
68 $1,397.82 $388.18 $348.02 $68.83 $279.17 $424.51 $309.78 $447.46 $70.74
69 $1,429.09 $396.87 $355.81 $70.37 $285.42 $434.01 $316.71 $457.47 $72.33
70 $1,446.08 $401.59 $360.04 $71.21 $288.81 $439.17 $320.48 $462.91 $73.19
71 $1,462.15 $406.05 $364.04 $72.00 $292.02 $444.05 $324.04 $468.06 $74.00
72 $1,477.19 $410.22 $367.79 $72.74 $295.02 $448.62 $327.37 $472.87 $74.76
73 $1,491.09 $414.08 $371.25 $73.42 $297.80 $452.84 $330.45 $477.32 $75.47
74 $1,522.54 $422.82 $379.08 $74.97 $304.08 $462.39 $337.42 $487.39 $77.06
75 $1,559.38 $433.05 $388.25 $76.79 $311.44 $473.58 $345.59 $499.18 $78.92
76 $1,617.08 $449.07 $402.61 $79.63 $322.96 $491.10 $358.37 $517.65 $81.84
77 $1,676.91 $465.69 $417.51 $82.57 $334.91 $509.27 $371.63 $536.80 $84.87
78 $1,738.95 $482.92 $432.96 $85.63 $347.30 $528.11 $385.38 $556.67 $88.01
79 $1,803.30 $500.79 $448.98 $88.80 $360.15 $547.65 $399.64 $577.26 $91.27
80 $1,834.64 $509.49 $456.78 $90.34 $366.41 $557.17 $406.59 $587.30 $92.85
81 $1,866.56 $518.36 $464.73 $91.91 $372.79 $566.87 $413.66 $597.52 $94.47
82 $1,898.96 $527.35 $472.80 $93.51 $379.26 $576.71 $420.84 $607.88 $96.11
83 $1,931.70 $536.45 $480.95 $95.12 $385.80 $586.65 $428.10 $618.37 $97.77
84 $1,964.80 $545.64 $489.19 $96.75 $392.41 $596.70 $435.43 $628.96 $99.44
85 $1,998.59 $555.02 $497.60 $98.41 $399.16 $606.97 $442.92 $639.78 $101.15
86 $2,022.57 $561.68 $503.57 $99.59 $403.95 $614.25 $448.24 $647.45 $102.36
87 $2,046.89 $568.43 $509.63 $100.79 $408.81 $621.63 $453.63 $655.24 $103.60
88 $2,071.45 $575.25 $515.74 $102.00 $413.71 $629.09 $459.07 $663.10 $104.84
89 $2,096.36 $582.17 $521.94 $103.23 $418.68 $636.66 $464.59 $671.08 $106.10
90 & $2,121.39 $589.12 $528.18 $104.46 $423.68 $644.26 $470.14 $679.09 $107.37
Older
Rates displayed are for the 2021 plan year and are subject to change. The rates in this book are specifically for
individuals residing in Baltimore City and the following counties: Baltimore, Harford, Howard and Anne Arundel.
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