R.C.S.A. § 38a-495 APPENDIX A

[Company Name] Notice of Changes in Medicare and your Medicare Supplement Coverage–199X The following chart briefly describes the modifications in Medicare and in your medicare supplement coverage. PLEASE READ THIS CAREFULLY! [A brief description of the revisions to Medicare Parts A & B with a parallel description of supplemental benefits with subsequent changes, including dollar amounts, provided by the Medicare supplement coverage in substantially the following format.] SERVICES MEDICARE BENEFITS Effective January 1, 199X, Medicare Will Pay YOUR MEDICARE SUPPLEMENT COVERAGE Effective January 1, 199X, Your Coverage Will Pay MEDICARE PART A SERVICE AND SUPPLIES Inpatient Hospital Services Semi-Private Room & Board Misc. Hospital Servivces & Supplies, such as Drugs, X-Rays, Lab Tests & Operating Rooom BLOOD SKILLED NURSING FACILITY CARE