23 CAR pt. 89, Appendix D. Benefit Chart of Medicare Supplement Coverage

Benefit Chart of Medicare Supplement Coverage-Cover Page:Plans With An Effective Date Of Coverage Prior To June 1, 201 0 [COMPANY NAME] Outline of Medicare Supplement Coverage-Cover Page: Benefit Plan(s) ____ {insert letter(s) of plan(s) being offered] These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan •A". Some plans may not be available in your state. See outlines of covel'llge sections for details about ALL plans. Basic Benefits¼ For Plans A- J: 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. Blood: First three pints of blood each year. A B C D E F* G Basic Basic Basic Basic Basic Basic Basic Benefits Benefits Benefits Benefits Benefits Benefits Benefits Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Co-Insurance Co-Insurance Co-Insurance Co-Insurance Co-Insurance Part A Part A Part A Part A Part A Part A Deductible Deductible Deductible Deductible Deductible Deductible Part B Part B Deductible Deductible Part B Excess Part B Excess (100%) (80%) Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign Travel Emeri,encv Emereencv Emereencv Emereencv Emereencv At-Home At-Home Recovery Recovery [ not available after December 31, 2005; so thereafter strike this line) Preventive Care NOT covered bvMedicare H Basic Benefits Skilled Nursing Co-Insurance Part A Deductible Foreign Travel Emereencv Basic Drugs ($1,250 Limit) I J. Basic Basic Benefits Benefits Skilled Nursing Skilled Nursing Co-Insurance Co-Insurance Part A Part A Deductible Deductible Part B Deductible Part B Excess Part B Excess (100%) fl00%) Foreign Travel Foreign Travel Emereencv Emcntencv At-Home At-Home Recoverv Recoverv Basic Drugs Extended Drugs ($ I ,250 Limit) ($3,000 Limit) Preventive Care NOT covered bv Medicare • Plans F and J also have an option called a high deductible plan F and a high deductible plan J. These high deductible plans pay the same or offer t.he same benefits as Plans F and J afler one has paid a calendar year IS I deductible. Benefits from high deductible plans F and J will not begin unlil out-of-pocket expenses are [S I- 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, bul does not include, in plan J, the plan's separate prescription drug deductible or, in Plans F and J, the plan's separate foreign travel emergency deductible. 47 Appendix D [COMPANY NAME] Outline of Medicare Supplement Coverage-Cover Page 2 Basic Benefits for Plans K and L include similar services as plans A-J, but cost sharing for the bask benefits is at different levels. K" L** Basic Benefits 100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End 50% Hospice cost-sharing 50510 of Medicare-eligible expenses for the first three pints of blood 50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services 100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End 75% Hospice cost-sharing 75% of Medicare-eligible expenses for the first three pints of blood 75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services Skilled Nursing Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Part A Deductible 50% Part A Deductible 75% Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency 1 At-Home Recovery Preventive Care NOT covered by Medicare $[4000] Out of Pocket Annual Limit*** $[2000] Out of Pocket Annual Limit*** ** Plans K and L provide for different cost-sharing for items and services than Plans A —J. Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges". You will be responsible for paying excess charges. ***The out-of-pocket annual limit will increase each year for inflation. See Outlines of Coverage for details and exceptions. 48 PREMIUM INFORMATION (Boldface Type) We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in Arkansas. DISCLOSURES [Boldface Type] Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY (Boldface Type) This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY [Boldface Type] If you find that you are not satisfied with your policy, you may return it to (insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. POLICY REPLACEMENT [Boldface Type] If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE (Boldface Type) This policy may not fully cover all of your medical costs. (for agents/producers:] Neither (insert company's name] nor its agents or producers are connected with Medicare. [for direct response:) [insert company's name) is not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "The Medicare Handbook" for more details. COMPLETE ANSWERS ARE VERY IMPORTANT (Boldface Type] When you fill out the application for the new policy, be sure to answer truthfully and completely 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. (lithe policy or certificate is guaranteed-issue, this paragraph need not appear.) Review the application carefully before you sign it. Be certain that all information has been properly recorded. [Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four (4) plans may be shown on one (I) chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to Section 9(D) of this rule.] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.] Benefit Chart of Medicare Supplement Plans Sold with an effective date of coverage on or After June 1, 2010 This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A" available. Some plans may not be available in your state. Plans E, H, I, and J are no longer available for sale. (This sentence shall not appear after June 1, 20111 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 co-payments 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 A B C D F Fs G Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance Basic, including 100% Part B coinsurance* Basic, including 100% Part B coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Ski I led Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part 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 *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 1$20001 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed [$2000]. 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. K L M N 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 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible i Foreign Travel Emergency Foreign Travel Emergency Out-of-pocket limit $[4620]; paid at 100% after limit reached Out-of-pocket ]imit 5[2310]; paid at 100% , after limit reached PREMIUM INFORMATION [Boldface Type] We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in Arkansas. DISCLOSURES [Boldface Type] Use this outline to compare benefits and premiums among policies. This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010. Policies sold for effective dates prior to June 1, 2010 have different benefits and premiums. Plans E, H, I, and J are no longer available for sale. [This paragraph shall not appear after June 1, 2011.] READ YOUR POLICY VERY CAREFULLY [Boldface Type] This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY [Boldface Type] If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments, POLICY REPLACEMENT [Boldface Type] If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE [Boldface Type] This policy may not fully cover all of your medical costs. [for agents:] Neither [insert company's name] nor its agents are connected with Medicare. [for direct response:] [insert company's name] is not connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT [Boldface Type] When you fill out the application for the new policy, be sure to answer truthfully and completely 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. [If the policy or certificate is guaranteed issue, this paragraph need not appear.] Review the application carefully before you sign it. Be certain that all information has been properly recorded. [Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this rule. An issuer may use additional benefit plan designations on these charts pursuant to Section 9.1D of this rule.] [Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the Commissioner.] Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020 This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Note: A Vmeans 100% of the benefit is paid. 4 ,,,„,„,:: Medicare eligible 2020 f bef onl; l tl C Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up) v# V V V V V  V V 1 Medicare Part B coinsurance or Copayment V V V V 50% 75% V V copays apply3 V Blood (first three pints) V V V V 50% 75% V V V Part A hospice care coinsurance or copayment V V V V 50% 75% V V V Skilled nursing facility coinsurance V V 50% 75% V V V Medicare Part A deductible V V V 50% 75% 50% V V Medicare Part B deductible V Medicare Part B excess charges V Foreign travel emergency (up to plan limits) V V  Out-of-pocket limit in [201712 [$5120] 15256012 Plans F and O also have a high deductible option which require first paying a plan deductible of r$22001 before the elan begins to ea . Once the elan deductible is met the i lan pays100% of covered services for the rest of the calendar y,ear. 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 co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission. PLAN A MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. V SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068 ] $0 $[ 1068 ] (Part A deductible) 61st thru 90th day All but $[ 267] a day $[ 267] a day $0 91st day and after: ---While using 60 lifetime reserve days All but $[534] a day $[534] a day $0 ---Once lifetime reserve days are used: 100% of Medicare ---Additional 365 days $0 eligible expenses $0** ---Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[133.50]a day $0 $0 $0 $0 $0 Up to $[13330] a day All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for out- patient drugs and inpatient respite care $0 Balance SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for out- patient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN A MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[135] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment 100% $0 $0 First $[135] of Medicare Approved Amounts* Remainder of Medicare $0 $0 $[135] (Part B deductible) Approved Amounts 80% 20% $0 PLAN B MEDICARE (PART A}—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[1068](Part A deductible) $0 61st thru 90th day All but $[267] a day $[267] a day $0 91" day and after: All but $[534] a day $[534] a day $0 —While using 60 lifetime reserve days —Once lifetime reserve days are used: $0 100% of Medicare eligible expenses $0** —Additional 365 days $0 $0 All costs —Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $[133.50] a day $0 Up to $[133.50] a day 101st day and after $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited Medicare co-payment/ $0 requirements, including a doctor's certification of terminal illness co-payment/ coinsurance for out- patient drugs and inpatient respite care coinsurance ** NOTICE; When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN B MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, F First $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[135] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 —Durable medical equipment First $[135] of Medicare Approved Amounts* $0 $0 $(1351 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 PLAN C MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[1068](Part A deductible) $0 61st thru 90th day All but $[267] a day $[267] a day $0 91' day and after: All but $[534] a day $[534] a day $0 —While using 60 lifetime reserve days $0** —Once lifetime reserve days are used: $0 100% of Medicare eligible expenses All costs Additional 365 days $0 $0 —Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21' thru 100th day All but $[133.50] a day Up to $[133.50] a day $0 101st day and after $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited Medicare co-payment/ $0 requirements, including a doctor's certification of terminal illness. co-payment/ coinsurance for out- patient drugs and inpatient respite care coinsurance ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN C MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $[135] (Part B deductible) Generally 20% $0 $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare _Approved Amounts $0 $0 80% All costs $[135] (Part B deductible) 20% $0 $0 $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment 100% $0 $0 First $[135] of Medicare Approved Amounts* Remainder of Medicare $0 $[135](PartB deductible) $0 Approved Amounts 80% 20% $0 OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL,— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum PLAN D MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[1068] (Part A deductible) $0 61st thru 90th day All but $[267] a day $[267] a day $0 91st day and after: All but $[534] a day $[534] a day $0 $0 —While using 60 lifetime reserve days —Once lifetime reserve days are used: $0 100% of Medicare eligible expenses $0** Additional 365 days $0 $0 All costs —Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21' thru 100th day All but 4133.50] a day Up to $[133.50] a day $0 101st day and after $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's All but very limited Medicare co-payment! $0 requirements, including a doctor's certification of terminal illness co-payment/ coinsurance for out- patient drugs and inpatient respite care coinsurance ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN D MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[135] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES .. 100% $0 $0 (continued) PLAN D PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment 100% $0 $0 First $[135] of Medicare Approved Amounts* Remainder of Medicare $0 $0 $[135] (Part B deductible) Approved Amounts 80% 20% $0 OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD • A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS RN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[1068] (Part A deductible) $0 61st thru 90th day All but $[267] a day $[267] a day $0 91st day and after: All but $[534] a day $[534] a day $0 —While using 60 Lifetime reserve days Once lifetime reserve days are used: $0 100% of Medicare eligible expenses $0*" —Additional 365 days Beyond the additional $0 $0 All costs 365 days SERVICES MEDICARE PAYS [AFTER YOU PAY $[2000] DEDUCTIBLE,**) PLAN PAYS [IN ADDITION TO $120001 DEDUCTIBLE,**] YOU PAY SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101' day and after All approved amounts All but $[133.50] a day $0 $0 Up to $[133.50] a day $0 $0 $0 All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for out- patient drugs and inpatient respite care Medicare co- payment/coinsuranc e $0 (continued) *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN F or HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year [$2000] deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are [$2000]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [AFTER YOU PAY $[2000] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2000] DEDUCTIBLE,**] YOU PAY MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, Such as physician's Services, inpatient and Outpatient medical and Surgical services and Supplies, physical and Speech therapy, Diagnostic tests, Durable medical Equipment, First $[135] of Medicare Approved amounts* $0 $[135] (Part B deductible) $0 Remainder of Medicare Approved amounts Generally 80% Generally 20% $0 Part B excess charges (Above Medicare $0 100% $0 Approved Amounts) BLOOD First 3 pints $0 All costs $0 Next $[135] of Medicare Approved amounts* $0 $[135] (Part B deductible) $0 Remainder of Medicare 80% 20% $0 Approved amounts SERVICES . MEDICARE PAYS [AFTER YOU PAY $(2000] DEDUCTIBLE, * 1 PLAN PAYS [IN ADDITION TO $120001 DEDUCTIBLE, *1 YOU PAY CLINICAL LABORATORY SERVICES—TESTS FOR. DIAGNOSTIC SERVICES 100% $0 $0 PLAN F or HIGH DEDUCTIBLE PLAN F PARTS A & B SERVICES MEDICARE PAYS AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS IN ADDITION TO $120001 DEDUCTIBLE, ** YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment First $[135] of Medicare Approved Amounts* $0 $[135) (Part B deductible) $0 Remainder of Medicare — Approved Amounts 80% 20% $0 OTHER BENEFITS - NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS AFTER YOU PAY $[2000] DEDUCTIBLE,** PLAN PAYS IN ADDITION TO $[2000] DEDUCTIBLE, ** YOU PAY FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically necessary Emergency care services Beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum This page is intentionally left blank PLAN G or HIGH DEDUCTIBLE PLAN G MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. [**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2200] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2200]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1316] $[1316] (Part A deductible) $0 61st thru 90th day All but $[329] a day $[329] a day $0 91st day and after: —While using 60 lifetime reserve days All but $[658] a day $[658] a day $0 —Once lifetime reserve days are used: $0 $0 —Additional 365 days 100% of Medicare eligible expenses $0*** All costs —Beyond the additional 365 days $0 PLAN G or HIGH DEDUCTIBLE PLAN G MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD (cont.) SERVICES MEDICARE PAYS [AFTER YOU PAY $[2200] DEDUCTIBLE,**1 PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[164.50] a day $0 $014 to $[164.50] a day$0 $0 $0 All costs BLOOD First 3 pints Additional amounts $0 100% 3 pints $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited co- payment/ coinsurance for out-patient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN G or HIGH DEDUCTIBLE PLAN G MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[183] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. [* *This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2200] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2200]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.] SERVICES MEDICARE PAYS [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[22001 DEDUCTIBLE,**] YOU PAY MEDICAL EXPENSES -IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[183] of Medicare Approved Amounts* $0 $0 $[183] (Unless Part B deductible has been met) Remainder of Medicare Generally 80% Generally 20% $0 Approved Amounts Part B Excess Charges (Above Medicare $0 100% $0 Approved Amounts) PLAN G or HIGH DEDUCTIBLE PLAN G MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR (cont.) SERVICES MEDICARE PAYS [AFTER YOU PAY $122001 DEDUC DEDUCTIBLE,**] DEDUCTIBLE,**1 PLAN PAYS [IN ADDITION TO $12200) YOU PAY BLOOD First 3 pints $0 All costs $0 Next $[183] of Medicare Approved Amounts* Remainder of Medicare $0 $0 $[183] (Unless Part B deductible has been met) Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PLAN G or HIGH DEDUCTIBLE PLAN G PARTS A & B SERVICES MEDICARE PAYS [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment 100% $0 $0 -First $[183] of Medicare Approved Amounts* $0 $0 $[183] (Unless Part B deductible has been met) -Remainder of Medicare Approved Amounts 80% 20% $0 PLAN G or HIGH DEDUCTIBLE PLAN G OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS [AFTER YOU PAY $[2200] DEDUCTIBLE,**] PLAN PAYS [IN ADDITION TO $[2200] DEDUCTIBLE,**] YOU PAY FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum PLAN K * You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[4620] each calendar year. The amounts that count toward your annual limit are noted with diamonds (+) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare co-payment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD ** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[534](50% of Part A deductible) $[534](50% of Part A deductible)* 61' thru 90th day All but $[267] a day $(267] a day $0 91st day and after: —While using All but $[534] a day $[534] a day $0 60 lifetime reserve days —Once lifetime reserve days are used: —Additional 365 days $0 100% of Medicare eligible expenses $0*** —Beyond the additional 365 days $0 $0 All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* SKILLED NURSING FACILITY CARE** You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility Within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts. All but $[133.50] a day $0 $0 Up to $[66.75] a day $0 $0 Up to $[66.75] a day • All costs BLOOD First 3 pints Additional amounts $0 100% 50% $0 50%♦ $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care 50% of co-payment/ coinsurance 50% of Medicare co- payment/coinsurance♦ (continued) *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN K MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[135] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 75% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 10% $[135] (Part B deductible)**** • All costs above Medicare approved amounts Generally 10% • Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual out-of-pocket limit of [$4620])* BLOOD First 3 pints Next $[135] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 50% $0 Generally 10% 50%♦ $[135] (Part B deductible)**** • Generally 10% CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 (continued) * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[4620] per year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN K PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment 100% $0 $0 First $[135] of Medicare Approved Amounts***** Remainder of Medicare $0 $0 $[135] (Part B deductible) . Approved Amounts 80% 10% 10%♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health insurance for People with Medicare. PLAN L * You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[2310] each calendar year. The amounts that count toward your annual limit are noted with diamonds (*) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD ** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[808.50] (75% of Part A deductible) $[267] (25% of Part A deductible)♦ 61st thru 90th day All but $[267] a day $[267] a day $0 91st day and after: All but $[534] a day $[534] a day $0 —While using 60 lifetime reserve days —Once lifetime reserve days are used: $0 100% of Medicare eligible expenses $0*** —Additional 365 days —Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE" You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility Within 30 days after leaving the hospital First 20 days 21st thru 100th day 101st day and after All approved amounts All but $[133.50] a day $0 $0 Up to $[100.13] a day $0 $0 Up to $[33.38] a day* All costs SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* BLOOD First 3 pints Additional amounts $0 100% 75% $0 25%* $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited co- payment/ coinsurance for outpatient drugs and inpatient respite care 75% of co-payment/ coinsurance _ 25% of co-payment/ coinsurance (continued) *** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN L MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR **** Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physi- cian's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment, First $[135] of Medicare Approved Amounts**** Preventive Benefits for Medicare covered services Remainder of Medicare Approved Amounts $0 Generally 75% or more of Medicare approved amounts Generally 80% $0 Remainder of Medicare approved amounts Generally 15% $[135] (Part B deductible)**** • All costs above Medicare approved amounts Generally 5% + Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs (and they do not count toward annual out-of-pocket limit of [$2310])* BLOOD First 3 pints Next $[135] of Medicare Approved Amounts**** Remainder of Medicare Approved Amounts $0 $0 Generally 80% 75% $0 Generally 15% 25%♦ $[135] (Part B deductible) • Generally 5%♦ CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 (continued) * This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[2310] per year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. PLAN L PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY* HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment 100% $0 $0 First $[135] of Medicare Approved Amounts***** Remainder of Medicare $0 $0 $[135] (Part B deductible) 4 Approved Amounts 80% 15% 5% ♦ *****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare. PLAN M MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[534](50% of Part A deductible) $[534](50% of Part A deductible) 61' thru 90th day All but $[267] a day $[267] a day $0 91' day and after: All but $[534] a day $[534] a day $0 —While using 60 lifetime reserve days —Once lifetime reserve days are used: $0 100% of Medicare eligible expenses $0** —Additional 365 days —Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21' thru 100th day All but $[133.50] a day Up to $[133.50] a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care Medicare co-payment/ coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN M MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment —First $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Generally 20% $[135] (Part B deductible) $0 Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[135] (Part B deductible) $0 CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 —Durable medical equipment $0 $0 $[135](PartB deductible) First $[135] of Medicare Approved Amounts* Remainder of Medicare $0 Approved Amounts 80% 20% OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum PLAN N MEDICARE (PART A)—HOSPITAL SERVICES—PER BENEFIT PERIOD * A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $[1068] $[1068](Part A deductible) $0 61s` thru 90th day All but $[267] a day $[267] a day $0 91st day and after: All but $[534] a day $[534] a day $0 —While using 60 lifetime reserve days —Once lifetime reserve days are used: $0 100% of Medicare eligible expenses $0** —Additional 365 days —Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th day All but $[133.50] a Up to $[133.50] a day $0 101st day and after day $0 All costs $0 BLOOD First 3 pints $() 3 pints $0 Additional amounts 1 00% so $0 SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care Medicare co-payment! coinsurance $0 ** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid. PLAN N MEDICARE (PART B)—MEDICAL SERVICES—PER CALENDAR YEAR * Once you have been billed $[135] of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 Generally 80% $0 Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co- payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. $[135] (Part B deductible) Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The co-payment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints Next $[135] of Medicare Approved Amounts* Remainder of Medicare Approved Amounts $0 $0 80% All costs $0 20% $0 $[135] (Part B deductible) $0 CLINICAL LABORATORY SERVICES--TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A & B SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies —Durable medical equipment 100% $0 $0 First $[135] of Medicare Approved Amounts* Remainder of Medicare $0 $0 $[135] (Part B deductible) Approved Amounts 80% 20% $0 OTHER BENEFITS—NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL— NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum