FORM #18803 Page 1

NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued.

QCC Insurance Company Outline of Medicare Supplement Coverage MedigapFreedom — Plans A, B, F, F High Deductible, G, G High Deductible, and N

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. Every company must make Plans A, B, and D or G available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F1.

_________________ Note: A means 100% of the benefit is paid.

Benefits

Plans Available to All Applicants

Medicare first eligible before 2020 only

A B D G1 K L M N C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment

50%

75%

copays apply3

Blood (first three pints) 50% 75%

Part A hospice care coinsurance or copayment 50% 75% Skilled nursing facility coinsurance 50% 75% Medicare Part A deductible 50% 75% 50% Medicare Part B deductible Medicare Part B excess charges

Foreign travel emergency (up to plan limits)

Out-of-pocket limit in 2020 2 $5,8802 $2,9402

1Plans F and G also have a high deductible option, which requires first paying a plan deductible of $2,340 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. 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. 2Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

FORM #18803 Page 2

QCC Insurance Company MedigapFreedom Premium Information

QCC Insurance Company can only raise your premium if we raise the premium for all policies like yours in our service area. We will not change your premium or cancel your policy because of poor health. These monthly rates are subject to change with the approval of the Pennsylvania Insurance Department.

MONTHLY NON-TOBACCO PREMIUMS MALE

Attained Age

FEMALE

Plan A Plan B Plan F Plan F-HD Plan G

Plan G-HD Plan N Plan A Plan B Plan F Plan

F-HD Plan G Plan G-HD Plan N

$131.08 $159.06 $200.80 $75.37 $181.55 $68.15 $139.97 Under 65* $119.16 $144.60 $182.55 $68.52 $165.05 $61.95 $127.25 $131.08 $159.06 $200.80 $75.37 $181.55 $68.15 $139.97 65-67 $119.16 $144.60 $182.55 $68.52 $165.05 $61.95 $127.25 $137.04 $166.30 $209.77 $78.80 $189.66 $71.25 $146.69 68 $124.58 $151.18 $190.70 $71.64 $172.42 $64.77 $133.35 $142.65 $173.10 $217.99 $82.02 $197.09 $74.16 $153.02 69 $129.68 $157.36 $198.17 $74.57 $179.17 $67.42 $139.11 $148.61 $180.33 $227.89 $85.45 $206.04 $77.26 $160.62 70 $135.10 $163.94 $207.17 $77.69 $187.31 $70.24 $146.02 $154.93 $188.01 $237.79 $89.09 $214.99 $80.55 $168.22 71 $140.85 $170.91 $216.17 $80.99 $195.45 $73.23 $152.93 $160.42 $194.66 $246.57 $92.24 $222.93 $83.40 $174.93 72 $145.84 $176.97 $224.15 $83.86 $202.67 $75.82 $159.03 $165.31 $200.60 $255.91 $95.06 $231.38 $85.94 $182.41 73 $150.28 $182.36 $232.64 $86.41 $210.34 $78.13 $165.82 $169.48 $205.66 $263.94 $97.46 $238.64 $88.11 $188.74 74 $154.08 $186.97 $239.95 $88.60 $216.94 $80.10 $171.58 $174.02 $211.16 $272.72 $100.06 $246.58 $90.47 $195.83 75 $158.20 $191.97 $247.93 $90.97 $224.16 $82.24 $178.03 $177.60 $215.50 $280.56 $102.12 $253.67 $92.33 $202.04 76 $161.45 $195.91 $255.06 $92.84 $230.61 $83.94 $183.67 $181.29 $219.99 $289.72 $104.25 $261.95 $94.25 $209.39 77 $164.81 $199.99 $263.38 $94.77 $238.13 $85.68 $190.35 $185.71 $225.35 $300.18 $106.78 $271.40 $96.55 $218.00 78 $168.82 $204.86 $272.89 $97.08 $246.73 $87.77 $198.18 $188.21 $228.39 $307.09 $108.22 $277.65 $97.85 $223.58 79 $171.10 $207.62 $279.17 $98.38 $252.41 $88.95 $203.25 $189.40 $229.83 $313.44 $108.91 $283.39 $98.47 $228.77 80 $172.18 $208.94 $284.95 $99.01 $257.63 $89.52 $207.97

(continued) *This includes people under 65 on Medicare due to disability. Non-Tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates.

FORM #18803 Page 3

MONTHLY NON-TOBACCO PREMIUMS (continued) MALE

Attained Age

FEMALE

Plan A Plan B Plan F Plan F-HD Plan G

Plan G-HD Plan N Plan A Plan B Plan F Plan

F-HD Plan G Plan G-HD Plan N

$192.27 $233.31 $324.09 $110.56 $293.02 $99.96 $237.76 81 $174.79 $212.10 $294.62 $100.50 $266.38 $90.87 $216.15 $195.01 $236.64 $335.86 $112.13 $303.66 $101.38 $247.64 82 $177.28 $215.12 $305.32 $101.94 $276.05 $92.17 $225.13 $195.49 $237.21 $344.07 $112.41 $311.09 $101.63 $254.74 83 $177.71 $215.65 $312.79 $102.19 $282.81 $92.39 $231.58 $195.61 $237.36 $351.73 $112.48 $318.02 $101.69 $261.45 84 $177.82 $215.78 $319.76 $102.25 $289.11 $92.45 $237.68 $197.18 $239.27 $359.02 $113.38 $324.60 $102.05 $267.91 85 $179.26 $217.52 $326.38 $103.08 $295.09 $92.77 $243.55 $200.98 $243.88 $365.93 $115.57 $330.85 $104.02 $274.24 86 $182.71 $221.71 $332.66 $105.06 $300.77 $94.56 $249.31 $205.29 $249.11 $373.77 $118.04 $337.94 $106.25 $281.08 87 $186.63 $226.46 $339.80 $107.31 $307.22 $96.59 $255.53 $207.54 $251.85 $377.88 $119.34 $341.66 $107.41 $284.63 88 $188.68 $228.95 $343.53 $108.49 $310.60 $97.65 $258.76 $210.73 $255.71 $383.67 $121.17 $346.90 $109.06 $290.08 89 $191.57 $232.46 $348.80 $110.15 $315.36 $99.15 $263.71 $215.34 $261.31 $392.08 $123.82 $354.50 $111.45 $297.93 90 $195.77 $237.55 $356.44 $112.57 $322.27 $101.32 $270.85 $220.88 $268.03 $402.17 $127.01 $363.62 $114.32 $306.92 91 $200.80 $243.66 $365.61 $115.46 $330.56 $103.92 $279.02 $221.31 $268.55 $412.25 $127.25 $372.74 $114.54 $315.79 92 $201.19 $244.13 $374.78 $115.69 $338.85 $104.12 $287.08 $228.88 $277.74 $416.74 $131.61 $376.79 $118.46 $319.97 93 $208.08 $252.49 $378.85 $119.65 $342.54 $107.69 $290.88 $231.86 $281.35 $422.15 $133.32 $381.69 $120.00 $324.91 94 $210.78 $255.77 $383.78 $121.20 $346.99 $109.09 $295.37 $234.83 $284.96 $427.57 $135.03 $386.58 $121.54 $329.73 95 $213.49 $259.06 $388.70 $122.76 $351.44 $110.49 $299.75 $237.40 $288.07 $432.24 $136.51 $390.81 $122.87 $334.16 96 $215.82 $261.89 $392.95 $124.10 $355.28 $111.70 $303.78 $241.30 $292.80 $439.34 $138.75 $397.22 $124.88 $340.62 97 $219.36 $266.19 $399.40 $126.14 $361.11 $113.53 $309.65 $244.58 $296.79 $445.32 $140.64 $402.63 $126.58 $346.07 98 $222.35 $269.81 $404.83 $127.85 $366.03 $115.08 $314.61 $247.86 $300.77 $451.29 $142.52 $408.03 $128.28 $351.51 99 $225.33 $273.43 $410.27 $129.57 $370.94 $116.62 $319.56

Non-Tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates.

QCC Insurance Company can only raise your premium if we raise the premium for all policies like yours in our service area. We will not change your premium or cancel your policy because of poor health. These monthly rates are subject to change with the approval of the Pennsylvania Insurance Department.

FORM #18803 Page 4

MONTHLY TOBACCO PREMIUMS MALE FEMALE

Plan A Plan B Plan F Plan F-HD Plan G

Plan G-HD Plan N Attained

Age Plan A Plan B Plan F Plan F-HD Plan G

Plan G-HD Plan N

$144.19 $174.97 $220.88 $82.91 $199.71 $74.96 $153.97 Under 65* $131.08 $159.06 $200.80 $75.37 $181.55 $68.15 $139.97 $144.19 $174.97 $220.88 $82.91 $199.71 $74.96 $153.97 65-67 $131.08 $159.06 $200.80 $75.37 $181.55 $68.15 $139.97 $150.75 $182.93 $230.75 $86.68 $208.63 $78.37 $161.35 68 $137.04 $166.30 $209.77 $78.80 $189.66 $71.25 $146.69 $156.91 $190.41 $239.79 $90.23 $216.80 $81.58 $168.32 69 $142.65 $173.10 $217.99 $82.02 $197.09 $74.16 $153.02 $163.47 $198.37 $250.68 $94.00 $226.65 $84.99 $176.68 70 $148.61 $180.33 $227.89 $85.45 $206.04 $77.26 $160.62 $170.43 $206.81 $261.57 $98.00 $236.49 $88.60 $185.04 71 $154.93 $188.01 $237.79 $89.09 $214.99 $80.55 $168.22 $176.46 $214.13 $271.22 $101.47 $245.23 $91.74 $192.43 72 $160.42 $194.66 $246.57 $92.24 $222.93 $83.40 $174.93 $181.84 $220.66 $281.50 $104.56 $254.51 $94.54 $200.65 73 $165.31 $200.60 $255.91 $95.06 $231.38 $85.94 $182.41 $186.43 $226.23 $290.33 $107.20 $262.50 $96.92 $207.61 74 $169.48 $205.66 $263.94 $97.46 $238.64 $88.11 $188.74 $191.42 $232.28 $299.99 $110.07 $271.23 $99.52 $215.42 75 $174.02 $211.16 $272.72 $100.06 $246.58 $90.47 $195.83 $195.35 $237.05 $308.62 $112.33 $279.04 $101.56 $222.25 76 $177.60 $215.50 $280.56 $102.12 $253.67 $92.33 $202.04 $199.42 $241.99 $318.69 $114.67 $288.14 $103.68 $230.33 77 $181.29 $219.99 $289.72 $104.25 $261.95 $94.25 $209.39 $204.28 $247.88 $330.20 $117.46 $298.54 $106.20 $239.80 78 $185.71 $225.35 $300.18 $106.78 $271.40 $96.55 $218.00 $207.03 $251.22 $337.80 $119.05 $305.42 $107.63 $245.93 79 $188.21 $228.39 $307.09 $108.22 $277.65 $97.85 $223.58 $208.34 $252.82 $344.78 $119.80 $311.73 $108.32 $251.65 80 $189.40 $229.83 $313.44 $108.91 $283.39 $98.47 $228.77

(continued) *This includes people under 65 on Medicare due to disability. Non-Tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates.

FORM #18803 Page 5

MONTHLY TOBACCO PREMIUMS (continued) MALE FEMALE

Plan A Plan B Plan F Plan F-HD Plan G

Plan G-HD Plan N Attained

Age Plan A Plan B Plan F Plan F-HD Plan G

Plan G-HD Plan N

$211.49 $256.64 $356.50 $121.61 $322.32 $109.95 $261.54 81 $192.27 $233.31 $324.09 $110.56 $293.02 $99.96 $237.76 $214.51 $260.30 $369.44 $123.35 $334.03 $111.52 $272.41 82 $195.01 $236.64 $335.86 $112.13 $303.66 $101.38 $247.64 $215.03 $260.94 $378.48 $123.65 $342.20 $111.79 $280.21 83 $195.49 $237.21 $344.07 $112.41 $311.09 $101.63 $254.74 $215.17 $261.09 $386.91 $123.72 $349.82 $111.86 $287.59 84 $195.61 $237.36 $351.73 $112.48 $318.02 $101.69 $261.45 $216.90 $263.20 $394.92 $124.72 $357.06 $112.26 $294.70 85 $197.18 $239.27 $359.02 $113.38 $324.60 $102.05 $267.91 $221.08 $268.27 $402.52 $127.12 $363.94 $114.42 $301.67 86 $200.98 $243.88 $365.93 $115.57 $330.85 $104.02 $274.24 $225.82 $274.02 $411.15 $129.85 $371.74 $116.87 $309.19 87 $205.29 $249.11 $373.77 $118.04 $337.94 $106.25 $281.08 $228.30 $277.03 $415.67 $131.27 $375.83 $118.16 $313.09 88 $207.54 $251.85 $377.88 $119.34 $341.66 $107.41 $284.63 $231.80 $281.28 $422.04 $133.29 $381.59 $119.97 $319.09 89 $210.73 $255.71 $383.67 $121.17 $346.90 $109.06 $290.08 $236.88 $287.44 $431.29 $136.21 $389.95 $122.59 $327.72 90 $215.34 $261.31 $392.08 $123.82 $354.50 $111.45 $297.93 $242.97 $294.83 $442.38 $139.71 $399.98 $125.75 $337.62 91 $220.88 $268.03 $402.17 $127.01 $363.62 $114.32 $306.92 $243.44 $295.40 $453.48 $139.98 $410.01 $125.99 $347.37 92 $221.31 $268.55 $412.25 $127.25 $372.74 $114.54 $315.79 $251.77 $305.51 $458.41 $144.77 $414.47 $130.30 $351.97 93 $228.88 $277.74 $416.74 $131.61 $376.79 $118.46 $319.97 $255.05 $309.49 $464.37 $146.65 $419.86 $132.00 $357.40 94 $231.86 $281.35 $422.15 $133.32 $381.69 $120.00 $324.91 $258.32 $313.46 $470.33 $148.54 $425.24 $133.69 $362.70 95 $234.83 $284.96 $427.57 $135.03 $386.58 $121.54 $329.73 $261.14 $316.88 $475.47 $150.16 $429.89 $135.15 $367.58 96 $237.40 $288.07 $432.24 $136.51 $390.81 $122.87 $334.16 $265.43 $322.08 $483.27 $152.62 $436.95 $137.37 $374.68 97 $241.30 $292.80 $439.34 $138.75 $397.22 $124.88 $340.62 $269.04 $326.47 $489.85 $154.70 $442.89 $139.24 $380.67 98 $244.58 $296.79 $445.32 $140.64 $402.63 $126.58 $346.07 $272.65 $330.85 $496.42 $156.78 $448.84 $141.11 $386.66 99 $247.86 $300.77 $451.29 $142.52 $408.03 $128.28 $351.51

Non-Tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six-month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates.

FORM #18803 Page 6

PREMIUM INFORMATION

We, QCC Insurance Company, can only raise your premium if we raise the premium for all policies like yours in the Commonwealth of Pennsylvania. Premiums for all of these attained age plans will increase beginning with the first full month that the member moved into a new age range in accordance with the premium schedule on the previous page.

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.

RIGHT TO RETURN YOUR POLICY If you find that you are not satisfied with your policy, you may return it to QCC Insurance Company, 1901 Market Street, Philadelphia, PA 19103-1480. 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 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 This policy may not fully cover all of your medical costs. QCC Insurance Company and its agents are 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 When you fill out the application for the new policy, be sure to answer truthfully and complete 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. Review the application carefully before you sign it. Be certain that all information has been properly recorded.

FORM #18803 Page 7

MedigapFreedom — PLAN A

MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 WITH PLAN A, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $0 $1,408 (Part A deductible) 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day $0 Up to $176.00 a day 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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.

(continued)

FORM #18803 Page 8

PLAN A (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A, 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 $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD

First three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

MEDICARE (PARTS A & B)

SERVICES MEDICARE PAYS PLAN A PAYS WITH PLAN A, YOU PAY HOME HEALTH CARE — MEDICARE-APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) • Remainder of Medicare-approved amounts 80% 20% $0

FORM #18803 Page 9

MedigapFreedom — PLAN B

MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 B PAYS WITH PLAN B, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day $0 Up to $176.00 a day 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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.

(continued)

FORM #18803 Page 10

PLAN B (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B, 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 $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-approved amounts) $0 $0 All costs BLOOD

First three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

MEDICARE (PARTS A & B)

SERVICES MEDICARE PAYS PLAN B PAYS WITH PLAN B, YOU PAY HOME HEALTH CARE — MEDICARE-APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) • Remainder of Medicare-approved amounts 80% 20% $0

FORM #18803 Page 11

MedigapFreedom — PLAN F

MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 F PAYS WITH PLAN F, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day Up to $176.00 a day $0 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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. (continued)

FORM #18803 Page 12

PLAN F (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, 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 $198 of Medicare-approved amounts† $0 $198 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD

First three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $198 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

MEDICARE (PARTS A & B) SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, YOU PAY HOME HEALTH CARE — MEDICARE-APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $198 (Part B deductible) $0 • Remainder of Medicare-approved amounts 80% 20% $0

OTHER BENEFITS — NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN F PAYS WITH PLAN F, 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

FORM #18803 Page 13

MedigapFreedom — PLAN F HIGH DEDUCTIBLE MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 $2,340 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,340. 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 $2,340

DEDUCTIBLE‡, PLAN F PAYS IN ADDITION TO $2,340 DEDUCTIBLE‡, YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day Up to $176.00 a day $0 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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.

FORM #18803 Page 14

PLAN F HIGH DEDUCTIBLE (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), 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 $2,340 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,340. 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 $2,340

DEDUCTIBLE‡, PLAN F PAYS

IN ADDITION TO $2,340 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 $198 of Medicare-approved amounts† $0 $198 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD

First three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $198 (Part B deductible) $0 Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

(continued)

FORM #18803 Page 15

PLAN F HIGH DEDUCTIBLE (continued)

MEDICARE (PARTS A & B) † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), 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 $2,340 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,340. 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 $2,340

DEDUCTIBLE‡, PLAN F PAYS

IN ADDITION TO $2,340 DEDUCTIBLE‡, YOU PAY

HOME HEALTH CARE — MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $198 (Part B deductible) $0 • Remainder of Medicare-approved amounts 80% 20% $0

OTHER BENEFITS — NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS AFTER YOU PAY $2,340

DEDUCTIBLE‡, PLAN F PAYS

IN ADDITION TO $2,340 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

FORM #18803 Page 16

MedigapFreedom — PLAN G

MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 WITH PLAN G, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day Up to $176.00 a day $0 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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.

(continued)

FORM #18803 Page 17

PLAN G (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN G PAYS WITH PLAN G, 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 $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD

First three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

(continued)

FORM #18803 Page 18

PLAN G (continued)

MEDICARE (PARTS A & B) † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN G PAYS WITH PLAN G, YOU PAY HOME HEALTH CARE — MEDICARE-APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) • Remainder of Medicare-approved amounts 80% 20% $0

OTHER BENEFITS — NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN G PAYS WITH PLAN G, 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

FORM #18803 Page 19

MedigapFreedom — PLAN G HIGH DEDUCTIBLE MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 one has paid a calendar year $2,340 deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are $2,340. 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 $2,340

DEDUCTIBLE‡, PLAN G PAYS IN ADDITION TO $2,340 DEDUCTIBLE‡, YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day Up to $176.00 a day $0 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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.

FORM #18803 Page 20

PLAN G HIGH DEDUCTIBLE (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. ‡This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,340 deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are $2,340. 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 $2,340

DEDUCTIBLE‡, PLAN G PAYS

IN ADDITION TO $2,340 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 $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Part B excess charges (above Medicare-approved amounts) $0 100% $0 BLOOD

First three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

(continued)

FORM #18803 Page 21

PLAN G HIGH DEDUCTIBLE (continued)

MEDICARE (PARTS A & B) † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. ‡This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2,340 deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are $2,340. 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 $2,340

DEDUCTIBLE‡, PLAN G PAYS

IN ADDITION TO $2,340 DEDUCTIBLE‡, YOU PAY

HOME HEALTH CARE — MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) • Remainder of Medicare-approved amounts 80% 20% $0

OTHER BENEFITS — NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS AFTER YOU PAY $2,340

DEDUCTIBLE‡, PLAN G PAYS

IN ADDITION TO $2,340 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

FORM #18803 Page 22

MedigapFreedom — PLAN N

MEDICARE (PART A) — HOSPITAL SERVICES — PER BENEFIT PERIOD * A benefit period begins on the first day you receive services 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 N PAYS WITH PLAN N, YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1,408 $1,408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after: • While using 60 lifetime reserve days All but $704 a day $704 a day $0 • Once lifetime reserve days are used: o Additional 365 days $0 100% of Medicare eligible

expenses $0**

o 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 three days and entered a Medicare-approved facility within 30 days after leaving the hospital.

First 20 days All approved amounts $0 $0 21st through 100th day All but $176.00 a day Up to $176.00 a day $0 101st day and after $0 $0 All costs

BLOOD First three pints $0 Three 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 for outpatient drugs and inpatient respite care

Medicare copayment/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. (continued)

FORM #18803 Page 23

PLAN N (continued)

MEDICARE (PART B) — MEDICAL SERVICES — PER CALENDAR YEAR † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, 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 $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Balance, other than up to

$20 per office visit and up to $50 per emergency room visit. The copayment 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.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment 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 three pints $0 All costs $0 Next $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% $0

CLINICAL LABORATORY SERVICES —TESTS FOR DIAGNOSTIC SERVICES

100% $0 $0

(continued)

FORM #18803 Page 24

PLAN N (continued)

MEDICARE (PARTS A & B) † Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with a dagger), your Part B deductible will have been met for the calendar year. SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, YOU PAY HOME HEALTH CARE — MEDICARE-APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment • First $198 of Medicare-approved amounts† $0 $0 $198 (Part B deductible) • Remainder of Medicare-approved amounts 80% 20% $0

OTHER BENEFITS — NOT COVERED BY MEDICARE SERVICES MEDICARE PAYS PLAN N PAYS WITH PLAN N, 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

Questions?

Need more information?

Call one of our Medicare sales representatives at 1-877-393-6733 (Speech- or hearing-impaired: 711)

Monday through Friday, 8 a.m. to 6 p.m. www.ibxmedicare.com

Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross—independent licensees of the Blue Cross and Blue Shield Association.

MF 8942 (04/19)