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Health Net Health Plan of Oregon, Inc.
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Medicare Supplement Plans & Rates Rates effective January 1, 2012 Plan A Plan F High Ded. F Plan K Plan M 67 & under - Region 1 (View brochure to see your Region) $78.00 $111.00 $46.00 $59.00 $94.00 67 & under - Region 2 (View brochure to see your Region) $82.00 $117.00 $48.00 $62.00 $98.00 67 & under - Region 3 (View brochure to see your Region) $83.00 $119.00 $49.00 $63.00 $100.00 Benefits Plan A Plan F High Ded. F Plan K Plan M Medicare Part A Coinsurance and Hospital Benefits Medicare Part A Deductible   50% 50% Medicare Part B Coinsurance or Co-payment 50% Medicare Part B Deductible       Medicare Part B Excess Charges       Blood (First Three Pints) 50% Hospice Care Coinsurance or Co-payment 50% Skilled Nursing Coinsurance   50% Foreign Travel Emergency (Up to Plan Limits)3     Medicare Preventive Care Part B Coinsurance

1. Medigap Plan F offers a high deductible option. You must pay for Medicare-covered costs up to the high-deductible amount ($2,070 in 2012) before your Medigap policy pays anything
2. 100% part B coinsurance except up to $20 copayment for office visits and up to $50 copayment for ER.
3. You must also pay a separate deductible for foreign travel emergency ($250 per year).
4. After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($140 in 2012) the plan pays 100% of covered services for the rest of the calendar year (This applies only to plans K & L)
5. Modified Plan F offers an individual assistance program, as well as coverage for preventive dental care (available in some states)

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