Omaha Insurance Company A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGE BENEFIT PLANS A, F, HIGH DEDUCTIBLE F, G AND N 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. 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 copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. Plan A Basic, including 100% Part B Coinsurance

Plan B Basic, including 100% Part B Coinsurance

Part A Deductible

Plan C Basic, including 100% Part B Coinsurance

Plan D Basic, including 100% Part B Coinsurance

Plan F F* Basic, including 100% Part B Coinsurance*

Plan G Basic, including 100% Part B Coinsurance

Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible

Skilled Nursing Facility Coinsurance Part A Deductible

Foreign Travel Emergency

Foreign Travel Emergency

Skilled Skilled Nursing Nursing Facility Co- Facility Coinsurance insurance Part A Part A Deductible Deductible Part B Deductible Part B Excess Part B Excess (100%) (100%) Foreign Foreign Travel Travel Emergency Emergency

Plan K Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Plan L Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%

Plan M Basic, including 100% Part B Coinsurance

50% Skilled Nursing 75% Skilled Nursing Skilled Nursing Facility Coinsurance Facility Coinsurance Facility Coinsurance 50% Part A Deductible

75% Part A Deductible

Plan N Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance

50% Part A Deductible

Part A Deductible

Foreign Travel Emergency

Foreign Travel Emergency

Out-of-pocket limit Out-of-pocket limit $4,960; paid at 100% $2,480; paid at 100% after limit reached after limit reached

*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 $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

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MONTHLY NON-TOBACCO PREMIUMS* ZIP CODES: 247 - 268

Plan A NM20

Plan F NM23

FEMALE Plan High F NM34

103.02 103.02 103.02 107.12 111.21 115.30 119.39 123.50 128.40 133.31 138.22 143.13 148.05 152.96 157.88 161.97 166.06 170.15 174.26 178.35 181.90 185.55 189.26 193.04 196.91 200.85 202.85 204.89 206.94 208.99 211.09 213.20 215.34 217.49 219.67

141.84 141.84 141.84 147.48 153.11 158.75 164.38 170.04 176.77 183.55 190.31 197.08 203.83 210.59 217.37 223.00 228.64 234.27 239.91 245.54 250.46 255.47 260.57 265.78 271.11 276.52 279.28 282.09 284.91 287.75 290.64 293.53 296.48 299.44 302.43

38.65 38.65 38.65 40.19 41.72 43.26 44.80 46.33 48.17 50.02 51.86 53.71 55.55 57.39 59.23 60.77 62.31 63.84 65.38 66.91 68.25 69.62 71.00 72.43 73.88 75.35 76.11 76.87 77.64 78.41 79.20 79.99 80.79 81.60 82.42

Plan G NM24

Plan N NM35

Attained Age

Plan A NM20

103.56 103.56 103.56 107.68 111.80 115.89 120.01 124.14 129.07 134.00 138.94 143.88 148.81 153.76 158.69 162.82 166.93 171.04 175.15 179.28 182.85 186.51 190.24 194.05 197.93 201.88 203.91 205.95 208.01 210.08 212.18 214.30 216.44 218.63 220.80

86.37 86.37 86.37 89.80 93.23 96.66 100.09 103.53 107.64 111.76 115.88 119.99 124.11 128.23 132.35 135.78 139.21 142.65 146.07 149.51 152.50 155.55 158.66 161.83 165.07 168.37 170.05 171.76 173.47 175.20 176.96 178.72 180.52 182.32 184.15

65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99+

114.47 114.47 114.47 119.02 123.56 128.12 132.66 137.22 142.67 148.14 153.59 159.05 164.51 169.96 175.42 179.97 184.52 189.06 193.62 198.16 202.13 206.16 210.29 214.50 218.79 223.16 225.39 227.65 229.93 232.22 234.54 236.90 239.26 241.65 244.07

Plan F NM23

MALE Plan High F NM34

Plan G NM24

Plan N NM35

157.62 157.62 157.62 163.86 170.12 176.39 182.65 188.93 196.42 203.95 211.46 218.98 226.49 234.01 241.52 247.79 254.04 260.30 266.57 272.83 278.28 283.86 289.53 295.33 301.22 307.25 310.31 313.43 316.57 319.73 322.91 326.15 329.42 332.70 336.04

42.95 42.95 42.95 44.65 46.36 48.07 49.78 51.49 53.53 55.58 57.62 59.67 61.72 63.77 65.82 67.52 69.23 70.93 72.64 74.34 75.84 77.35 78.90 80.48 82.08 83.73 84.57 85.41 86.26 87.13 88.00 88.88 89.77 90.66 91.57

115.07 115.07 115.07 119.64 124.21 128.77 133.35 137.93 143.41 148.90 154.38 159.87 165.36 170.84 176.33 180.90 185.48 190.04 194.60 199.19 203.16 207.25 211.38 215.61 219.91 224.31 226.56 228.82 231.12 233.42 235.76 238.12 240.51 242.90 245.34

95.96 95.96 95.96 99.78 103.58 107.39 111.21 115.04 119.60 124.18 128.75 133.33 137.90 142.48 147.05 150.87 154.68 158.50 162.30 166.12 169.44 172.83 176.28 179.82 183.41 187.07 188.95 190.84 192.75 194.67 196.61 198.58 200.58 202.57 204.60

*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.

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MONTHLY TOBACCO PREMIUMS* ZIP CODES: 247 - 268

Plan A NM20

Plan F NM23

FEMALE Plan High F NM34

118.42 118.42 118.42 123.13 127.82 132.53 137.23 141.95 147.59 153.23 158.88 164.52 170.17 175.81 181.47 186.17 190.87 195.58 200.30 205.00 209.08 213.28 217.54 221.89 226.33 230.86 233.16 235.50 237.86 240.22 242.63 245.06 247.51 249.98 252.50

163.04 163.04 163.04 169.51 175.99 182.47 188.94 195.44 203.19 210.97 218.74 226.53 234.29 242.06 249.85 256.33 262.80 269.28 275.76 282.23 287.89 293.64 299.51 305.49 311.62 317.84 321.01 324.24 327.48 330.75 334.07 337.39 340.78 344.18 347.63

44.43 44.43 44.43 46.19 47.96 49.73 51.49 53.26 55.37 57.49 59.61 61.73 63.85 65.97 68.08 69.85 71.62 73.38 75.15 76.91 78.45 80.02 81.61 83.25 84.92 86.61 87.48 88.36 89.24 90.13 91.03 91.95 92.86 93.79 94.74

Plan G NM24

Plan N NM35

Attained Age

Plan A NM20

119.03 119.03 119.03 123.77 128.50 133.21 137.95 142.69 148.35 154.02 159.70 165.38 171.05 176.74 182.41 187.14 191.87 196.59 201.32 206.07 210.18 214.38 218.67 223.05 227.51 232.05 234.38 236.72 239.09 241.48 243.89 246.32 248.78 251.29 253.80

99.27 99.27 99.27 103.22 107.16 111.11 115.05 118.99 123.72 128.46 133.19 137.92 142.65 147.39 152.12 156.07 160.01 163.96 167.90 171.85 175.28 178.79 182.36 186.01 189.74 193.53 195.46 197.43 199.39 201.38 203.40 205.43 207.49 209.56 211.66

65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99+

131.58 131.58 131.58 136.80 142.03 147.27 152.48 157.72 163.99 170.28 176.54 182.82 189.09 195.36 201.63 206.86 212.09 217.31 222.55 227.77 232.33 236.96 241.71 246.56 251.49 256.50 259.07 261.67 264.29 266.92 269.59 272.29 275.01 277.75 280.54

Plan F NM23

MALE Plan High F NM34

Plan G NM24

Plan N NM35

181.17 181.17 181.17 188.35 195.54 202.74 209.94 217.16 225.78 234.42 243.05 251.70 260.33 268.98 277.61 284.81 292.00 299.20 306.40 313.60 319.86 326.27 332.79 339.46 346.23 353.16 356.68 360.26 363.87 367.50 371.16 374.88 378.64 382.41 386.25

49.37 49.37 49.37 51.32 53.29 55.25 57.21 59.18 61.53 63.88 66.23 68.59 70.94 73.30 75.65 77.61 79.57 81.53 83.50 85.45 87.17 88.91 90.69 92.50 94.35 96.24 97.21 98.17 99.15 100.15 101.14 102.16 103.19 104.21 105.25

132.26 132.26 132.26 137.52 142.77 148.02 153.28 158.54 164.83 171.15 177.45 183.76 190.07 196.37 202.68 207.93 213.19 218.44 223.68 228.96 233.52 238.22 242.97 247.83 252.77 257.83 260.42 263.01 265.65 268.30 270.98 273.70 276.44 279.19 282.00

110.30 110.30 110.30 114.69 119.06 123.44 127.83 132.22 137.47 142.73 147.99 153.25 158.51 163.77 169.03 173.41 177.79 182.18 186.56 190.94 194.76 198.65 202.63 206.69 210.82 215.02 217.18 219.36 221.55 223.76 225.99 228.25 230.55 232.84 235.18

*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.

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Disclosures Use this outline to compare benefits and premiums among policies.

Read Your Policy Very Carefully 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.

Premium Information We, Omaha Insurance Company, can only raise your premium if we raise the premium for all the policies like yours in the same geographic area of the state Right to Return Policy where you live. Until you are age 99, your premium may change each year. If you find that you are not satisfied with your policy, you may return it to Mutual of Omaha Plaza, Omaha, NE 68175. If you send the policy back to us Risk Class Rating within 30 days after you receive it, we will treat the policy as if it had never If, according to our underwriting standards, you are overweight or underweight been issued and return all of your payments. for your height, you will be considered to be a greater insurable risk. In such a case, your premium will be priced either as Class I – 10% or Class II – 20% Policy Replacement If you are replacing another health insurance policy, do NOT cancel it until you higher than the rates illustrated, based on your Body Mass Index (BMI) have actually received your new policy and are sure you want to keep it. reading. Risk class rating will not be applicable when you apply for coverage during an open enrollment or guaranteed issue period. Notice The policy may not fully cover all of your medical costs. Neither Omaha Household Premium Discount You are eligible for a household premium discount if: (a) you reside with your Insurance Company nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare Coverage. Contact your spouse (including civil union/domestic partner) of any age or (b) for the past year you have resided with at least one, but not more than three, other adults local Social Security office or consult “Medicare & You” for more details. who are age 60 or older. The discounted premium will be priced 12% lower Complete Answers Are Very Important than the rates illustrated. The policy’s household premium discount will be removed if the other adult or spouse no longer resides with you (other than in 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 the case of his or her death). Company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded. Exclusions Exclusions apply to your coverage. Please be sure to review the exclusions in your policy. This policy does not cover Part A benefits for benefit periods that begin while this policy is not in force, and other exclusions apply.

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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. Services Medicare Pays Plan A Pays HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies

You Pay

First 60 days All but $1,288 $0 $1,288 (Part A deductible) st th 61 through 90 day All but $322 a day $322 a day $0 std 91 day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 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 SKILLED NURSING FACILITY CARE* - You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 st th 21 through 100 day All but $161.00 a day $0 Up to $161.00 a day st 101 day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE - You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/coinsurance Medicare copayment/ coinsurance $0 for outpatient drugs and inpatient respite care ** NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy’s/certificate’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.

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PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $166 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 A Pays You Pay MEDICAL EXPENSES - IN OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved amounts * $0 Remainder of Medicare-approved amounts Generally 80% Part B Excess Charges (above Medicare-approved amounts)

$0 Generally 20%

$166 (Part B deductible) $0

$0

All costs

All costs $0 20%

$0 $166 (Part B deductible) $0

$0

$0

100%

$0

$0

$0 80%

$0 20%

$166 (Part B deductible) $0

$0 BLOOD First 3 pints $0 Next $166 of Medicare-approved amounts * $0 Remainder of Medicare-approved amounts 80% CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100% PARTS A AND B HOME HEALTH CARE – MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies DURABLE MEDICAL EQUIPTMENT First $166 of Medicare-approved amounts Remainder of Medicare-approved amounts

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PLANS F AND HIGH DEDUCTIBLE 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. You Pay (In Plan High Deductible F addition to Pays $2,180 (After you pay $2,180 deductible***) deductible***) Services Medicare Pays Plan F Pays You Pay HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A $0 $1,288 (Part A $0 deductible) deductible) 61st through 90th day All but $322 a day $322 a day $0 $322 a day $0 91st day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0 Once lifetime reserve days are used 100% of Medicare100% of Medicare$0** (Additional 365 days): $0 eligible expenses $0** eligible expenses Beyond the additional 365 days $0 $0 All costs $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 Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 $0 $0 st th 21 through 100 day All but $161.00 a day Up to $161 a day $0 Up to $161 a day $0 101st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $0 $0 HOSPICE CARE - You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited copayment/ Medicare $0 Medicare copayment/ $0 coinsurance for outpatient drugs copayment/ coinsurance and inpatient respite care coinsurance ** NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy’s/certificate’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. *** High deductible plan F pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

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PLANS F AND HIGH DEDUCTIBLE F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $166 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. Plan High Deductible F You Pay (In Pays addition to $2,180 (After you pay $2,180 deductible***) deductible***) Services Medicare Pays Plan F Pays You Pay MEDICAL EXPENSES - IN OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved amounts * $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 100% $0 BLOOD First 3 pints $0 All costs $0 All costs $0 Next $166 of Medicare-approved amounts * $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 20% $0 CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100%

$0

$0

$0

$0

PARTS A AND B HOME HEALTH CARE – MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 DURABLE MEDICAL EQUIPMENT First $166 of Medicare-approved amounts $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0 20% $0 *** High deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/ certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

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PLANS F AND HIGH DEDUCTIBLE F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR OTHER BENEFITS – NOT COVERED BY MEDICARE Plan High Deductible F Pays (After you pay $2,180 deductible***)

Services Medicare Pays Plan F 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 $0 80% to a lifetime Remainder of charges $0 80% to a lifetime maximum 20% and amounts maximum benefit of benefit of $50,000 over the $50,000 $50,000 lifetime maximum benefit

You Pay (In addition to $2,180 deductible***)

$250 20% and amounts over the $50,000 lifetime maximum benefit

*** High deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

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PLANS G AND 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 G Pays You Pay Plan N Pays You Pay HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A $0 $1,288 (Part A $0 deductible) deductible) 61st through 90th day All but $322 a day $322 a day $0 $322 a day $0 st 91 day and after (while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0 Once lifetime reserve days are used 100% of Medicare100% of Medicare(Additional 365 days): $0 eligible expenses $0** eligible expenses $0** Beyond the additional 365 days $0 $0 All costs $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 Medicareapproved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 $0 $0 st th 21 through 100 day All but $161.00 a day Up to $161 a day $0 Up to $161 a day $0 101st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $0 $0 HOSPICE CARE - You must meet Medicare’s requirements, including a doctor’s certification of terminal illness. All but very limited Medicare copayment/ $0 Medicare copayment/ $0 copayment/ coinsurance for coinsurance coinsurance outpatient drugs and inpatient respite care ** NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy’s/certificate’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.

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PLANS G AND N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR *Once you have been billed $166 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 G Pays You Pay Plan N Pays You Pay MEDICAL EXPENSES - IN OUR OUT OF THE HOSPTIAL 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 $166 of Medicare-approved $0 $0 $166 (Part B $0 $166 (Part B deductible) amounts * deductible) Remainder of Medicare-approved Generally 80% Generally 20% $0 Balance, other than up to $20 Up to $20 per office visit and amounts per office visit and up to $50 up to $50 per emergency room visit. The copayment per emergency room visit. The copayment of up to $50 of up to $50 is waived if the insured is admitted to any is waived if the insured is admitted to any hospital and hospital and the emergency visit is covered as a the emergency visit is covered as a Medicare Part A Medicare Part A expense. expense. Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 $0 All costs BLOOD First 3 pints $0 All costs $0 All costs $0 Next $166 of Medicare-approved $0 $0 $166 (Part B $0 $166 (Part B deductible) amounts * deductible) Remainder of Medicare-approved 80% 20% $0 20% $0 amounts CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES 100%

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$0

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$0

$0

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PLANS G AND N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR PARTS A AND B Services Medicare Pays Plan G Pays HOME HEALTH CARE – MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 DURABLE MEDICAL EQUPMENT First $166 of Medicare-approved $0 $0 amounts Remainder of Medicare-approved 80% 20% amounts

You Pay

Plan N Pays

You Pay

$0

$0

$0

$166 (Part B deductible) $0

$0

$166 (Part B deductible)

20%

$0

OTHER BENEFITS – NOT COVERED BY MEDICARE Services Medicare Pays Plan G 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 20% and amounts maximum benefit of over the $50,000 $50,000 lifetime maximum benefit

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Plan N Pays

You Pay

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 lifetime maximum benefit

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