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. 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 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 2,870 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,870. 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 $6,6207,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,610; paid at 100% after limit reached MPL00037 v1.25 An independent licensee of the Blue Cross and Blue Shield Association. Blue Cross & G 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 sexsex (consistent with the scope of sex discrimination required under federal law). BCBSRI provides reasonable modifications and free appropriate auxiliary aids and services services, and language assistance services, to people with disabilities and to people whose primary language is not English when such services are necessary to ensure accessibility and to communicate effectively with us. If you need these services, contact us at ▇-▇▇▇-▇▇▇-▇▇▇▇ 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 withwith us through the Corporate Compliance Officer: Director of • by mailing the Corporate Compliance Officer c/o Grievance and Appeals Department, Blue Cross & G Blue Shield of Rhode Island, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or • by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) -▇▇▇-▇▇▇▇ or electronically through our member portal at (TTY/TDD: 711), • by sending an email to ▇▇▇_▇▇▇▇▇▇▇▇▇▇_▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇/, or • by faxing ▇▇▇-▇▇▇-▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-10191016, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. This notice is available at BCBSRI’s website: ▇▇▇▇▇▇.▇▇▇

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. 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 2,870 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,870. 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 $6,6207,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,610; paid at 100% after limit reached MPL00032 v1.25 An independent licensee of the Blue Cross and Blue Shield Association. Blue Cross & G 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 sexsex (consistent with the scope of sex discrimination required under federal law). BCBSRI provides reasonable modifications and free appropriate auxiliary aids and services services, and language assistance services, to people with disabilities and to people whose primary language is not English when such services are necessary to ensure accessibility and to communicate effectively with us. If you need these services, contact us at ▇-▇▇▇-▇▇▇-▇▇▇▇ 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 withwith us through the Corporate Compliance Officer: Director of • by mailing the Corporate Compliance Officer c/o Grievance and Appeals Department, Blue Cross & G Blue Shield of Rhode Island, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or • by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) -▇▇▇-▇▇▇▇ or electronically through our member portal at (TTY/TDD: 711), • by sending an email to ▇▇▇_▇▇▇▇▇▇▇▇▇▇_▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇/, or • by faxing ▇▇▇-▇▇▇-▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-10191016, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. This notice is available at BCBSRI’s website: ▇▇▇▇▇▇.▇▇▇

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. 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 2,870 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,870. 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 $6,6207,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,610; paid at 100% after limit reached MPL00033 v1.25 An independent licensee of the Blue Cross and Blue Shield Association. Blue Cross & G 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 sexsex (consistent with the scope of sex discrimination required under federal law). BCBSRI provides reasonable modifications and free appropriate auxiliary aids and services services, and language assistance services, to people with disabilities and to people whose primary language is not English when such services are necessary to ensure accessibility and to communicate effectively with us. If you need these services, contact us at ▇-▇▇▇-▇▇▇-▇▇▇▇ 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 withwith us through the Corporate Compliance Officer: Director of • by mailing the Corporate Compliance Officer c/o Grievance and Appeals Department, Blue Cross & G Blue Shield of Rhode Island, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or • by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) -▇▇▇-▇▇▇▇ or electronically through our member portal at (TTY/TDD: 711), • by sending an email to ▇▇▇_▇▇▇▇▇▇▇▇▇▇_▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇/, or • by faxing ▇▇▇-▇▇▇-▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-10191016, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. This notice is available at BCBSRI’s website: ▇▇▇▇▇▇.▇▇▇

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. 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 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 2,800 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,800. 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 $6,6207,060; paid at 100% after limit reached Out-of- pocket limit $3,3103,530; paid at 100% after limit reached MPL00032 v1.24 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 2,870 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,870. 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 $6,6207,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,610; paid at 100% after limit reached MPL00053 v1.25 An independent licensee of the Blue Cross and Blue Shield Association. Blue Cross & G 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 sexsex (consistent with the scope of sex discrimination required under federal law). BCBSRI provides reasonable modifications and free appropriate auxiliary aids and services services, and language assistance services, to people with disabilities and to people whose primary language is not English when such services are necessary to ensure accessibility and to communicate effectively with us. If you need these services, contact us at ▇-▇▇▇-▇▇▇-▇▇▇▇ 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 withwith us through the Corporate Compliance Officer: Director of • by mailing the Corporate Compliance Officer c/o Grievance and Appeals Department, Blue Cross & G Blue Shield of Rhode Island, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or • by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) -▇▇▇-▇▇▇▇ or electronically through our member portal at (TTY/TDD: 711), • by sending an email to ▇▇▇_▇▇▇▇▇▇▇▇▇▇_▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇/, or • by faxing ▇▇▇-▇▇▇-▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-10191016, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. This notice is available at BCBSRI’s website: ▇▇▇▇▇▇.▇▇▇

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. 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 2,800 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,800. 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 $6,6207,060; paid at 100% after limit reached Out-of- pocket limit $3,3103,530; paid at 100% after limit reached MPL00033 v1.24 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ • 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇▇▇-▇▇▇-▇▇▇▇ or ▇▇▇-▇▇▇-▇▇▇▇ (TTY/TDD: 711888-252-5051). You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ -▇▇▇▇, or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr//ocr/ portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 2,800 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,800. 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 $6,6207,060; paid at 100% after limit reached Out-of- pocket limit $3,3103,530; paid at 100% after limit reached MPL00006 v1.24 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/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. 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 2,870 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,870. 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 $6,6207,220; paid at 100% after limit reached Out-of- pocket limit $3,3103,610; paid at 100% after limit reached MPL00040 v1.25 An independent licensee of the Blue Cross and Blue Shield Association. Blue Cross & G 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 sexsex (consistent with the scope of sex discrimination required under federal law). BCBSRI provides reasonable modifications and free appropriate auxiliary aids and services services, and language assistance services, to people with disabilities and to people whose primary language is not English when such services are necessary to ensure accessibility and to communicate effectively with us. If you need these services, contact us at ▇-▇▇▇-▇▇▇-▇▇▇▇ 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 withwith us through the Corporate Compliance Officer: Director of • by mailing the Corporate Compliance Officer c/o Grievance and Appeals Department, Blue Cross & G Blue Shield of Rhode Island, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or • by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) -▇▇▇-▇▇▇▇ or electronically through our member portal at (TTY/TDD: 711), • by sending an email to ▇▇▇_▇▇▇▇▇▇▇▇▇▇_▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇/, or • by faxing ▇▇▇-▇▇▇-▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-10191016, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html. This notice is available at BCBSRI’s website: ▇▇▇▇▇▇.▇▇▇

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. 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 2,800 deductible. Benefits fromhigh from high deductible plan F will not begin until out-of-pocket expenses exceed $2,4902,800. 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 $6,6207,060; paid at 100% after limit reached Out-of- pocket limit $3,3103,530; paid at 100% after limit reached MPL00040 v1.24 An independent licensee of the Blue Cross and Blue Shield Association. 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 ▇-▇▇▇-▇▇▇-▇▇▇▇ 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, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇, or by calling ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: 711. You can file a grievance in person, by phone or by mail, fax at (▇▇▇) ▇▇▇-▇▇▇▇ or electronically through our member portal at ▇▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇▇. 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 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/ ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇.▇. ▇▇▇▇▇ 800-368-1019, ▇▇▇-▇▇▇-▇▇▇▇ (TDD). Complaint forms are available at ▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/ocr/office/file/index.html.