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LOYAL AMERICAN LIFE INSURANCE COMPANY P. O. BOX 26580 ♦ AUSTIN, TX 78755-0580 ♦ 866-459-4272

Outline of Medicare Supplement Coverage - Benefit Plans A, C, 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 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 F* G K L M N Basic, Including 100% Part B Coinsurance

Basic, Including 100% Part B Coinsurance



Basic, Including 100% Part B Coinsurance*


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, Except Up to $20 Copayment for Office Visit, and up to $50 Copayment for ER Visit

Skilled Nursing Facility Coinsurance




50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance



Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

50% Part A Deductible



Part A Deductible

Part B Deductible

Part B Deductible

Part B Excess (100%)

Part B Excess (100%)

Foreign Travel Emergency






Out-of-Pocket Limit $4,940; Paid at 100% After Reached

Out-of-Pocket Limit $2,470; Paid At 100% After 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 $2,140 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,140. 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.

LY-OC-AA-NJ PAGE 1 01/14

Plan A Plan C Plan F Plan G Plan NAttained

Age Plan A Plan C Plan F Plan G Plan N2,229.23 Under 65 2,563.60

1,507.47 2,229.23 1,857.69 1,598.57 1,273.00 65 1,733.59 2,563.60 2,136.33 1,838.35 1,463.951,507.47 2,229.23 1,857.69 1,598.57 1,273.00 66 1,733.59 2,563.60 2,136.33 1,838.35 1,463.951,575.32 2,326.36 1,938.64 1,676.35 1,332.74 67 1,811.62 2,675.31 2,229.43 1,927.81 1,532.631,642.39 2,419.11 2,015.92 1,750.63 1,390.63 68 1,888.74 2,781.99 2,318.32 2,013.22 1,599.221,708.26 2,514.02 2,095.01 1,826.64 1,448.54 69 1,964.51 2,891.12 2,409.27 2,100.62 1,665.821,772.04 2,602.23 2,168.52 1,897.27 1,503.07 70 2,037.85 2,992.56 2,493.80 2,181.85 1,728.521,825.01 2,687.43 2,239.53 1,965.49 1,557.85 71 2,098.75 3,090.54 2,575.45 2,260.31 1,791.531,877.98 2,772.62 2,310.52 2,033.72 1,612.62 72 2,159.67 3,188.52 2,657.10 2,338.78 1,854.521,930.94 2,857.82 2,381.52 2,101.94 1,667.39 73 2,220.58 3,286.50 2,738.75 2,417.23 1,917.501,983.91 2,943.02 2,452.52 2,170.16 1,722.18 74 2,281.50 3,384.47 2,820.39 2,495.69 1,980.492,038.91 3,031.25 2,526.04 2,240.63 1,778.73 75 2,344.74 3,485.94 2,904.95 2,576.73 2,045.532,086.37 3,122.44 2,602.04 2,311.80 1,838.30 76 2,399.33 3,590.81 2,992.35 2,658.56 2,114.042,134.59 3,215.16 2,679.30 2,384.15 1,898.87 77 2,454.77 3,697.43 3,081.19 2,741.77 2,183.712,185.72 3,312.69 2,760.58 2,460.16 1,962.42 78 2,513.57 3,809.59 3,174.66 2,829.18 2,256.782,237.71 3,411.98 2,843.32 2,537.55 2,027.14 79 2,573.36 3,923.77 3,269.81 2,918.18 2,331.212,290.59 3,513.05 2,927.54 2,616.35 2,093.04 80 2,634.18 4,040.00 3,366.67 3,008.79 2,407.002,349.98 3,637.40 3,031.17 2,712.56 2,175.91 81 2,702.48 4,183.02 3,485.85 3,119.45 2,502.302,410.47 3,764.24 3,136.87 2,810.73 2,260.47 82 2,772.04 4,328.88 3,607.40 3,232.33 2,599.542,474.52 3,897.43 3,247.86 2,913.72 2,349.07 83 2,845.71 4,482.05 3,735.04 3,350.78 2,701.432,539.83 4,033.46 3,361.22 3,018.92 2,439.58 84 2,920.81 4,638.49 3,865.41 3,471.76 2,805.522,606.41 4,172.38 3,476.98 3,126.36 2,532.06 85 2,997.38 4,798.23 3,998.53 3,595.32 2,911.862,677.57 4,318.91 3,599.09 3,238.77 2,628.31 86 3,079.19 4,966.75 4,138.96 3,724.58 3,022.572,750.43 4,469.36 3,724.47 3,354.21 2,727.22 87 3,162.98 5,139.76 4,283.14 3,857.34 3,136.312,825.04 4,623.84 3,853.20 3,472.77 2,828.84 88 3,248.79 5,317.42 4,431.18 3,993.68 3,253.162,898.60 4,777.73 3,981.44 3,590.96 2,930.34 89 3,333.39 5,494.38 4,578.65 4,129.60 3,369.892,970.92 4,930.65 4,108.88 3,708.53 3,031.50 90 3,416.56 5,670.25 4,725.21 4,264.81 3,486.233,041.25 5,087.52 4,239.60 3,828.71 3,135.86 91 3,497.45 5,850.65 4,875.55 4,403.02 3,606.233,112.92 5,247.65 4,373.04 3,951.40 3,242.41 92 3,579.85 6,034.79 5,028.99 4,544.12 3,728.773,179.64 5,400.38 4,500.31 4,068.58 3,344.59 93 3,656.59 6,210.43 5,175.36 4,678.87 3,846.273,247.45 5,555.85 4,629.88 4,187.87 3,448.61 94 3,734.57 6,389.22 5,324.35 4,816.04 3,965.903,316.36 5,714.07 4,761.73 4,309.27 3,554.53 95 3,813.82 6,571.18 5,475.98 4,955.66 4,087.713,382.69 5,828.35 4,856.96 4,395.46 3,625.63 96 3,890.10 6,702.61 5,585.51 5,054.77 4,169.463,450.36 5,944.92 4,954.10 4,483.37 3,698.14 97 3,967.90 6,836.66 5,697.22 5,155.88 4,252.853,519.36 6,063.82 5,053.18 4,573.03 3,772.10 98 4,047.26 6,973.39 5,811.16 5,259.00 4,337.913,589.75 6,185.10 5,154.25 4,664.50 3,847.54 99 4,128.20 7,112.86 5,927.39 5,364.17 4,424.67

Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted premium by 0.52, for quarterly premiums, multiply the above quoted premium by 0.265,

and for monthly bank draft premiums, multiply the above-quoted premium by 0.0833.

Loyal American Life Insurance CompanyMEDICARE SUPPLEMENT

Add one-time enrollment fee of $20.00 to the first premium.

NEW JERSEYAttained Age Rates -- Effective 5/16/2013 -- Area I (070-089)

MALE RATESFEMALE RATES

PREFERRED ANNUAL RATES



Age Plan A Plan C Plan F Plan G Plan N185.69 Under 65 213.55

125.57 185.69 154.75 133.16 106.04 65 144.41 213.55 177.96 153.13 121.95125.57 185.69 154.75 133.16 106.04 66 144.41 213.55 177.96 153.13 121.95131.22 193.79 161.49 139.64 111.02 67 150.91 222.85 185.71 160.59 127.67136.81 201.51 167.93 145.83 115.84 68 157.33 231.74 193.12 167.70 133.22142.30 209.42 174.51 152.16 120.66 69 163.64 240.83 200.69 174.98 138.76147.61 216.77 180.64 158.04 125.21 70 169.75 249.28 207.73 181.75 143.99152.02 223.86 186.55 163.73 129.77 71 174.83 257.44 214.53 188.28 149.23156.44 230.96 192.47 169.41 134.33 72 179.90 265.60 221.34 194.82 154.48160.85 238.06 198.38 175.09 138.89 73 184.97 273.77 228.14 201.36 159.73165.26 245.15 204.29 180.77 143.46 74 190.05 281.93 234.94 207.89 164.97169.84 252.50 210.42 186.64 148.17 75 195.32 290.38 241.98 214.64 170.39173.79 260.10 216.75 192.57 153.13 76 199.86 299.11 249.26 221.46 176.10177.81 267.82 223.19 198.60 158.18 77 204.48 308.00 256.66 228.39 181.90182.07 275.95 229.96 204.93 163.47 78 209.38 317.34 264.45 235.67 187.99186.40 284.22 236.85 211.38 168.86 79 214.36 326.85 272.38 243.08 194.19190.81 292.64 243.86 217.94 174.35 80 219.43 336.53 280.44 250.63 200.50195.75 303.00 252.50 225.96 181.25 81 225.12 348.45 290.37 259.85 208.44200.79 313.56 261.30 234.13 188.30 82 230.91 360.60 300.50 269.25 216.54206.13 324.66 270.55 242.71 195.68 83 237.05 373.35 311.13 279.12 225.03211.57 335.99 279.99 251.48 203.22 84 243.30 386.39 321.99 289.20 233.70217.11 347.56 289.63 260.43 210.92 85 249.68 399.69 333.08 299.49 242.56223.04 359.77 299.80 269.79 218.94 86 256.50 413.73 344.78 310.26 251.78229.11 372.30 310.25 279.41 227.18 87 263.48 428.14 356.79 321.32 261.25235.33 385.17 320.97 289.28 235.64 88 270.62 442.94 369.12 332.67 270.99241.45 397.98 331.65 299.13 244.10 89 277.67 457.68 381.40 344.00 280.71247.48 410.72 342.27 308.92 252.52 90 284.60 472.33 393.61 355.26 290.40253.34 423.79 353.16 318.93 261.22 91 291.34 487.36 406.13 366.77 300.40259.31 437.13 364.27 329.15 270.09 92 298.20 502.70 418.91 378.53 310.61264.86 449.85 374.88 338.91 278.60 93 304.59 517.33 431.11 389.75 320.39270.51 462.80 385.67 348.85 287.27 94 311.09 532.22 443.52 401.18 330.36276.25 475.98 396.65 358.96 296.09 95 317.69 547.38 456.15 412.81 340.51281.78 485.50 404.58 366.14 302.01 96 324.05 558.33 465.27 421.06 347.32287.41 495.21 412.68 373.46 308.06 97 330.53 569.49 474.58 429.48 354.26293.16 505.12 420.93 380.93 314.22 98 337.14 580.88 484.07 438.07 361.35299.03 515.22 429.35 388.55 320.50 99 343.88 592.50 493.75 446.84 368.58

Due to rounding, actual premium charged may vary slightly from rates shown above. System rates prevail.



PREFERRED MONTHLY BANK DRAFT RATES

FEMALE RATES MALE RATES




Age Plan A Plan C Plan F Plan G Plan N2,452.15 Under 65 2,819.96

1,658.21 2,452.15 2,043.46 1,758.43 1,400.29 65 1,906.96 2,819.96 2,349.96 2,022.18 1,610.341,658.21 2,452.15 2,043.46 1,758.43 1,400.29 66 1,906.96 2,819.96 2,349.96 2,022.18 1,610.341,732.86 2,558.99 2,132.49 1,843.99 1,466.01 67 1,992.79 2,942.85 2,452.38 2,120.59 1,685.901,806.63 2,661.03 2,217.52 1,925.70 1,529.69 68 2,077.62 3,060.17 2,550.14 2,214.54 1,759.141,879.09 2,765.43 2,304.52 2,009.29 1,593.38 69 2,160.96 3,180.24 2,650.20 2,310.69 1,832.401,949.25 2,862.44 2,385.37 2,086.99 1,653.38 70 2,241.63 3,291.82 2,743.18 2,400.04 1,901.382,007.50 2,956.17 2,463.48 2,162.04 1,713.63 71 2,308.63 3,399.60 2,833.00 2,486.35 1,970.682,065.77 3,049.88 2,541.57 2,237.08 1,773.89 72 2,375.64 3,507.36 2,922.80 2,572.65 2,039.962,124.03 3,143.61 2,619.67 2,312.14 1,834.14 73 2,442.64 3,615.14 3,012.62 2,658.96 2,109.262,182.30 3,237.32 2,697.77 2,387.19 1,894.39 74 2,509.64 3,722.93 3,102.44 2,745.27 2,178.552,242.80 3,334.38 2,778.65 2,464.69 1,956.60 75 2,579.23 3,834.53 3,195.44 2,834.41 2,250.092,295.01 3,434.68 2,862.23 2,542.98 2,022.12 76 2,639.27 3,949.89 3,291.57 2,924.42 2,325.442,348.04 3,536.67 2,947.23 2,622.57 2,088.76 77 2,700.25 4,067.17 3,389.31 3,015.95 2,402.072,404.29 3,643.96 3,036.63 2,706.18 2,158.67 78 2,764.93 4,190.55 3,492.12 3,112.10 2,482.462,461.48 3,753.17 3,127.64 2,791.31 2,229.85 79 2,830.71 4,316.16 3,596.80 3,210.00 2,564.332,519.64 3,864.36 3,220.30 2,877.98 2,302.35 80 2,897.59 4,444.02 3,703.35 3,309.67 2,647.712,584.99 4,001.14 3,334.28 2,983.82 2,393.51 81 2,972.72 4,601.32 3,834.43 3,431.40 2,752.542,651.52 4,140.66 3,450.55 3,091.80 2,486.52 82 3,049.25 4,761.75 3,968.13 3,555.56 2,859.492,721.97 4,287.18 3,572.65 3,205.09 2,583.97 83 3,130.28 4,930.25 4,108.54 3,685.85 2,971.572,793.82 4,436.81 3,697.34 3,320.81 2,683.55 84 3,212.89 5,102.33 4,251.94 3,818.93 3,086.072,867.06 4,589.61 3,824.68 3,439.00 2,785.25 85 3,297.11 5,278.05 4,398.37 3,954.85 3,203.052,945.32 4,750.80 3,959.00 3,562.65 2,891.15 86 3,387.11 5,463.41 4,552.84 4,097.05 3,324.813,025.47 4,916.29 4,096.91 3,689.64 2,999.95 87 3,479.28 5,653.74 4,711.45 4,243.08 3,449.933,107.55 5,086.22 4,238.52 3,820.04 3,111.72 88 3,573.67 5,849.15 4,874.29 4,393.05 3,578.483,188.47 5,255.50 4,379.58 3,950.05 3,223.39 89 3,666.73 6,043.82 5,036.52 4,542.57 3,706.893,268.02 5,423.72 4,519.77 4,079.37 3,334.66 90 3,758.22 6,237.28 5,197.73 4,691.29 3,834.853,345.38 5,596.28 4,663.56 4,211.58 3,449.45 91 3,847.19 6,435.72 5,363.10 4,843.33 3,966.863,424.22 5,772.41 4,810.34 4,346.53 3,566.64 92 3,937.84 6,638.27 5,531.89 4,998.52 4,101.643,497.60 5,940.42 4,950.35 4,475.44 3,679.04 93 4,022.25 6,831.48 5,692.90 5,146.75 4,230.903,572.20 6,111.42 5,092.85 4,606.64 3,793.47 94 4,108.03 7,028.14 5,856.78 5,297.64 4,362.503,648.01 6,285.48 5,237.90 4,740.20 3,909.98 95 4,195.21 7,228.31 6,023.59 5,451.23 4,496.493,720.97 6,411.19 5,342.66 4,835.01 3,988.19 96 4,279.12 7,372.86 6,144.05 5,560.26 4,586.413,795.39 6,539.41 5,449.51 4,931.70 4,067.94 97 4,364.70 7,520.33 6,266.94 5,671.46 4,678.143,871.30 6,670.20 5,558.50 5,030.34 4,149.30 98 4,451.99 7,670.74 6,392.28 5,784.88 4,771.703,948.72 6,803.60 5,669.67 5,130.94 4,232.29 99 4,541.03 7,824.15 6,520.13 5,900.58 4,867.14

Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted premium by 0.52, for quarterly premiums, multiply the above quoted premium by 0.265,

and for monthly bank draft premiums, multiply the above-quoted premium by 0.0833.

NEW JERSEY


Attained Age Rates -- Effective 5/16/2013 -- Area I (070-089)


STANDARD ANNUAL RATES




Age Plan A Plan C Plan F Plan G Plan N204.26 Under 65 234.90

138.13 204.26 170.22 146.48 116.64 65 158.85 234.90 195.75 168.45 134.14138.13 204.26 170.22 146.48 116.64 66 158.85 234.90 195.75 168.45 134.14144.35 213.16 177.64 153.60 122.12 67 166.00 245.14 204.28 176.65 140.44150.49 221.66 184.72 160.41 127.42 68 173.07 254.91 212.43 184.47 146.54156.53 230.36 191.97 167.37 132.73 69 180.01 264.91 220.76 192.48 152.64162.37 238.44 198.70 173.85 137.73 70 186.73 274.21 228.51 199.92 158.38167.22 246.25 205.21 180.10 142.75 71 192.31 283.19 235.99 207.11 164.16172.08 254.06 211.71 186.35 147.77 72 197.89 292.16 243.47 214.30 169.93176.93 261.86 218.22 192.60 152.78 73 203.47 301.14 250.95 221.49 175.70181.79 269.67 224.72 198.85 157.80 74 209.05 310.12 258.43 228.68 181.47186.83 277.75 231.46 205.31 162.98 75 214.85 319.42 266.18 236.11 187.43191.17 286.11 238.42 211.83 168.44 76 219.85 329.03 274.19 243.60 193.71195.59 294.60 245.50 218.46 173.99 77 224.93 338.80 282.33 251.23 200.09200.28 303.54 252.95 225.42 179.82 78 230.32 349.07 290.89 259.24 206.79205.04 312.64 260.53 232.52 185.75 79 235.80 359.54 299.61 267.39 213.61209.89 321.90 268.25 239.74 191.79 80 241.37 370.19 308.49 275.70 220.55215.33 333.29 277.75 248.55 199.38 81 247.63 383.29 319.41 285.84 229.29220.87 344.92 287.43 257.55 207.13 82 254.00 396.65 330.55 296.18 238.20226.74 357.12 297.60 266.98 215.24 83 260.75 410.69 342.24 307.03 247.53232.73 369.59 307.99 276.62 223.54 84 267.63 425.02 354.19 318.12 257.07238.83 382.31 318.60 286.47 232.01 85 274.65 439.66 366.38 329.44 266.81245.35 395.74 329.78 296.77 240.83 86 282.15 455.10 379.25 341.28 276.96252.02 409.53 341.27 307.35 249.90 87 289.82 470.96 392.46 353.45 287.38258.86 423.68 353.07 318.21 259.21 88 297.69 487.23 406.03 365.94 298.09265.60 437.78 364.82 329.04 268.51 89 305.44 503.45 419.54 378.40 308.78272.23 451.80 376.50 339.81 277.78 90 313.06 519.57 432.97 390.78 319.44278.67 466.17 388.47 350.82 287.34 91 320.47 536.10 446.75 403.45 330.44285.24 480.84 400.70 362.07 297.10 92 328.02 552.97 460.81 416.38 341.67291.35 494.84 412.36 372.80 306.46 93 335.05 569.06 474.22 428.72 352.43297.56 509.08 424.23 383.73 316.00 94 342.20 585.44 487.87 441.29 363.40303.88 523.58 436.32 394.86 325.70 95 349.46 602.12 501.77 454.09 374.56309.96 534.05 445.04 402.76 332.22 96 356.45 614.16 511.80 463.17 382.05316.16 544.73 453.94 410.81 338.86 97 363.58 626.44 522.04 472.43 389.69322.48 555.63 463.02 419.03 345.64 98 370.85 638.97 532.48 481.88 397.48328.93 566.74 472.28 427.41 352.55 99 378.27 651.75 543.13 491.52 405.43

Due to rounding, actual premium charged may vary slightly from rates shown above. System rates prevail.



STANDARD MONTHLY BANK DRAFT RATES




PREMIUM INFORMATION Your premium will increase each year because of the increase in your attained age. We, Loyal American Life Insurance Company, can also raise your premium if (a) we change the rates which apply to all policies of this form issued by us and in-force in your state; or (b) coverage under Medicare changes. We will send you a written notice at least thirty (30) days in advance when we change the premium rates for all policies of this form issued by us and in-force in your state. There will be a one-time enrollment fee of $20 added to the first premium. 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 Loyal American Life Insurance Company. 30-DAY RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Loyal American Life Insurance Company, P. O. Box 26580, Austin, TX 78755-0580. If you send the policy back to us within thirty (30) days after you receive it, we will treat the policy as if it had never been issued and return all of your premiums. 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. Neither Loyal American Life Insurance Company nor its agents are 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 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 completely all questions about your medical and health history. We 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. RENEWABILITY This policy is guaranteed renewable for life.


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 YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: – While using 60 lifetime reserve days – Once lifetime reserve days are used:

– Additional 365 days – Beyond the additional 365 days

All but $1,216 All but $304 a day All but $608 a day $0 $0

$0 $304 a day $608 a day 100% of Medicare Eligible Expenses $0

$1,216 (Part A Deductible) $0 $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 $152 a day $0

$0 $0 $0

$0 Up to $152 a day 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 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 A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $147 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 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 $147 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Generally 20%

$147 (Part B Deductible) $0

PART B EXCESS CHARGES (Above Medicare-approved amounts)

$0

$0

All costs

BLOOD First 3 pints Next $147 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 $0 80%

All costs $0 20%

$0 $147 (Part B Deductible) $0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY

HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies – Durable medical equipment First $147 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%



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 C PAYS YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days 61st thru 90th day 91st day and after: – While using 60 lifetime reserve days – Once lifetime reserve days are used:

– Additional 365 days

– Beyond the additional 365 days


$1,216 (Part A Deductible) $304 a day $608 a day 100% of Medicare Eligible Expenses $0

$0 $0 $0 $0** All costs



$0 Up to $152 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0


All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care


$0



PLAN C MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR




$0 Generally 80%

$147 (Part B Deductible) Generally 20%

$0 $0


$0

$0

All costs


$0 $0 80%

All costs $147 (Part B Deductible) 20%

$0 $0 $0


100%

$0

$0

PARTS A & B



100% $0 80%

$0 $147 (Part B Deductible) 20%

$0 $0 $0


PLAN C MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (CONTINUED)

OTHER BENEFITS – NOT COVERED BY MEDICARE


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 Remainder of charges

$0 $0

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

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


PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY






$0 $0 $0 $0** All costs



$0 Up to $152 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0


All but very limited co-payment/coinsurance for out-patient drugs and inpatient respite care


$0



PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR




$0 Generally 80%

$147 (Part B Deductible) Generally 20%

$0 $0


$0

100%

$0


$0 $0 80%

All costs $147 (Part B Deductible) 20%

$0 $0 $0


100%

$0

$0

PARTS A & B



100% $0 80%

$0 $147 (Part B Deductible) 20%

$0 $0 $0


PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (CONTINUED)



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 Remainder of charges

$0 $0




PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY






$0 $0 $0 $0** All costs



$0 Up to $152 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0




$0



PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR




$0 Generally 80%

$0 Generally 20%

$147 (Part B Deductible) $0


$0

100%

$0


$0 $0 80%

All costs $0 20%



100%

$0

$0

PARTS A & B



100% $0 80%

$0 $0 20%



PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (CONTINUED)


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 Remainder of charges

$0 $0




PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY






$0 $0 $0 $0** All costs



$0 Up to $152 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0




$0



PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR




$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

$147 (Part B Deductible) 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


$0

$0

All costs


$0 $0 80%

All costs $0 20%



100%

$0

$0


PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (CONTINUED)

PARTS A & B



100% $0 80%

$0 $0 20%




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 Remainder of Charges

$0 $0




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