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TRANSCRIPT
OH
8107
7NM
20
Page
1
Hum
ana
Bene
fit P
lan
of Il
linoi
s, In
c. of
fers
Pla
ns
A, F
, Hig
h De
duct
ible
F, G
, Hig
h De
duct
ible
G a
nd N
Bene
fit C
hart
of M
edica
re S
uppl
emen
t Pla
ns S
old
on o
r Aft
er Ja
nuar
y 1,
202
0Th
is ch
art s
how
s th
e be
nefit
s in
clud
ed in
eac
h of
the
stan
dard
Med
icar
e su
pple
men
t pla
ns. S
ome
plan
s m
ay n
ot b
e av
aila
ble.
Onl
y ap
plic
ants
firs
t el
igib
le fo
r Med
icar
e be
fore
202
0 m
ay p
urch
ase
Plan
s C,
F, a
nd h
igh
dedu
ctib
le F
. N
ote:
A ¸
mea
ns 1
00%
of t
he b
enef
it is
paid
.
Plan
s Ava
ilabl
e to
All
Appl
ican
ts
Med
icar
e fir
st e
ligib
le
befo
re 2
020
only
Be
nefit
s A
BD
G1K
LM
NC
F1
Med
icar
e Pa
rt A
Co
insu
ranc
e an
d ho
spita
l cov
erag
e (u
p to
an
addi
tiona
l 365
day
s af
ter
Med
icar
e be
nefit
s ar
e us
ed u
p)
¸¸
¸¸
¸¸
¸¸
¸¸
Med
icar
e Pa
rt B
Coin
sura
nce
or
Copa
ymen
t ¸
¸¸
¸50
%
75%
¸
¸co
pays
ap
ply3
¸¸
Bloo
d (f
irst t
hree
pin
ts)
¸¸
¸¸
50%
75
%
¸¸
¸¸
Part
AH
ospi
ce C
are
Coin
sura
nce
or
Copa
ymen
t ¸
¸¸
¸50
%
75%
¸
¸¸
¸
Skill
ed N
ursi
ng F
acili
ty C
oins
uran
ce
N/A
N
/A
¸¸
50%
75
%
¸¸
¸¸
Med
icar
e Pa
rt A
Dedu
ctib
le
N/A
¸
¸¸
50
%
75%
50
%
¸¸
¸M
edic
are
Part
BDe
duct
ible
N
/A
N/A
N
/A
N/A
N
/A
N/A
N
/A
N/A
¸
¸M
edic
are
Part
BEx
cess
Cha
rges
N
/A
N/A
N
/A
¸N
/A
N/A
N
/A
N/A
N
/A
¸Fo
reig
n Tr
avel
Em
erge
ncy
(up
to p
lan
limits
) N
/A
N/A
¸
¸N
/A
N/A
¸
¸¸
¸
Out
of P
ocke
t Lim
it in
202
1 2N
/A
N/A
N
/A
N/A
$6
,220
2$3
,110
2N
/A
N/A
N
/A
N/A
1Pl
ans
Fan
d G
also
hav
e a
high
ded
uctib
le o
ptio
n w
hich
requ
ire fi
rst p
ayin
g a
plan
ded
uctib
le o
f $2,
370
befo
re th
e pl
an b
egin
s to
pay
. Onc
e th
e
plan
ded
uctib
le is
met
, the
pla
n pa
ys 1
00%
of c
over
ed s
ervi
ces
for t
he re
st o
f the
cale
ndar
yea
r. H
igh
Dedu
ctib
le P
lan
Gdo
es n
ot c
over
the
Med
icar
e Pa
rt B
dedu
ctib
le. H
owev
er, h
igh
dedu
ctib
le p
lans
Fan
d G
coun
t you
r pay
men
t of
the
Med
icar
e Pa
rt B
dedu
ctib
le t
owar
d m
eetin
g th
e pl
an d
educ
tible
. 2
Plan
s K
and
Lpa
y 10
0% o
f cov
ered
ser
vice
s fo
r the
rest
of t
he c
alen
dar y
ear o
nce
you
mee
t th
e ou
t-of
-poc
ket
year
ly li
mit.
3
Plan
Npa
ys 1
00%
of t
he P
art B
coin
sura
nce,
exc
ept f
or a
copa
ymen
t of
up
to $
20 fo
r som
e of
fice
visi
ts a
nd u
p to
a$5
0 co
paym
ent
for
emer
genc
y ro
om v
isits
that
do
not r
esul
t in
an
inpa
tient
adm
issi
on.
Page
2O
H81
077N
M20
Prem
ium
Rat
ing
Area
Cla
ssifi
catio
nU
se th
is pa
ge to
iden
tify
your
ratin
g ar
ea fo
r ass
istan
ce in
det
erm
inin
g yo
ur m
onth
ly p
rem
ium
. Ple
ase
loca
te y
our c
ount
y be
low
.
Area
1: (P
rem
ium
rate
s be
gin
on p
age
Asht
abul
a, B
elm
ont,
Colu
mbi
ana,
Cuy
ahog
a, D
efia
nce,
Ful
ton,
Gea
uga,
Gue
rnse
y, H
arris
on, H
enry
, Jef
fers
on, L
ake,
Lor
ain,
Luc
as, M
ahon
ing,
Med
ina,
Mon
roe,
O
ttaw
a, P
orta
ge, S
andu
sky,
Tru
mbu
ll, W
ashi
ngto
n, W
illiam
s, W
ood
Area
2: (P
rem
ium
rate
s be
gin
on p
age
Adam
s, B
row
n, B
utle
r, Ch
ampa
ign,
Cla
rk, C
lerm
ont,
Clin
ton,
Dar
ke, D
elaw
are,
Fay
ette
, Fra
nklin
, Gal
lia, G
reen
e, H
amilt
on, H
ighl
and,
Jac
kson
, Law
renc
e,
Mad
ison,
Mia
mi,
Mon
tgom
ery,
Mor
row
, Pic
kaw
ay, P
ike,
Pre
ble,
Ros
s, S
ciot
o, S
helb
y, S
umm
it, U
nion
, War
ren
Area
3: (P
rem
ium
rate
s be
gin
on p
age
Alle
n, A
shla
nd, A
then
s, A
ugla
ize, C
arro
ll, C
osho
cton
, Cra
wfo
rd, E
rie, F
airfi
eld,
Han
cock
, Har
din,
Hoc
king
, Hol
mes
, Hur
on, K
nox,
Lic
king
, Log
an, M
ario
n, M
eigs
, M
erce
r, M
orga
n, M
uski
ngum
, Nob
le, P
auld
ing,
Per
ry, P
utna
m, R
ichl
and,
Sen
eca,
Sta
rk, T
usca
raw
as, V
an W
ert,
Vint
on, W
ayne
, Wya
ndot
3) 8) 14)
OH
8107
7NM
20
Page
3
Hum
anaM
edica
re Su
pple
men
t Are
a 1M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
FHi
gh
Dedu
ctib
le
Plan
FPl
an G
High
De
duct
ible
Pl
an G
Plan
N
65 -M
ale
P
refe
rred
$110
.61
$192
.92
$54.
27
$156
.36
$53.
75
$114
.69
65-M
ale
S
tand
ard
$126
.89
$221
.55
$62.
11
$179
.52
$61.
51
$131
.59
65-F
emal
e
Pre
ferr
ed$1
04.3
8 $1
81.9
7 $5
1.28
$1
47.5
1 $5
0.79
$1
08.2
3 65
- Fem
ale
S
tand
ard
$119
.74
$208
.97
$58.
67
$169
.34
$58.
10
$124
.17
66 -M
ale
P
refe
rred
$114
.27
$199
.35
$56.
03
$161
.56
$55.
49
$118
.48
66-M
ale
S
tand
ard
$131
.11
$228
.95
$64.
14
$185
.49
$63.
52
$135
.96
66-F
emal
e
Pre
ferr
ed$1
07.6
2 $1
87.6
8 $5
2.84
$1
52.1
1 $5
2.33
$1
11.6
0 66
- Fem
ale
S
tand
ard
$123
.47
$215
.53
$60.
46
$174
.64
$59.
88
$128
.04
67 -M
ale
P
refe
rred
$118
.04
$205
.99
$57.
85
$166
.93
$57.
30
$122
.40
67-M
ale
S
tand
ard
$135
.45
$236
.59
$66.
23
$191
.66
$65.
59
$140
.47
67-F
emal
e
Pre
ferr
ed$1
10.9
7 $1
93.5
7 $5
4.45
$1
56.8
8 $5
3.93
$1
15.0
7 67
- Fem
ale
S
tand
ard
$127
.32
$222
.30
$62.
31
$180
.11
$61.
72
$132
.03
68 -M
ale
P
refe
rred
$121
.94
$212
.85
$59.
73
$172
.48
$59.
15
$126
.46
68-M
ale
S
tand
ard
$139
.94
$244
.49
$68.
39
$198
.05
$67.
73
$145
.12
68-F
emal
e
Pre
ferr
ed$1
14.4
3 $1
99.6
4 $5
6.11
$1
61.7
9 $5
5.57
$1
18.6
6 68
- Fem
ale
S
tand
ard
$131
.29
$229
.28
$64.
22
$185
.76
$63.
60
$136
.15
69 -M
ale
P
refe
rred
$125
.99
$219
.95
$61.
68
$178
.21
$61.
07
$130
.65
69-M
ale
S
tand
ard
$144
.58
$252
.64
$70.
62
$204
.64
$69.
93
$149
.94
69-F
emal
e
Pre
ferr
ed$1
17.9
8 $2
05.8
9 $5
7.83
$1
66.8
5 $5
7.27
$1
22.3
5 69
- Fem
ale
S
tand
ard
$135
.39
$236
.49
$66.
20
$191
.58
$65.
55
$140
.40
70 -M
ale
P
refe
rred
$130
.15
$227
.28
$63.
68
$184
.15
$63.
07
$134
.97
70-M
ale
S
tand
ard
$149
.38
$261
.08
$72.
93
$211
.47
$72.
22
$154
.92
70-F
emal
e
Pre
ferr
ed$1
21.6
6 $2
12.3
6 $5
9.60
$1
72.0
8 $5
9.02
$1
26.1
7 70
- Fem
ale
S
tand
ard
$139
.61
$243
.91
$68.
23
$197
.59
$67.
57
$144
.79
71 -M
ale
P
refe
rred
$134
.46
$234
.88
$65.
75
$190
.28
$65.
12
$139
.45
71-M
ale
S
tand
ard
$154
.34
$269
.80
$75.
32
$218
.52
$74.
59
$160
.07
71-F
emal
e
Pre
ferr
ed$1
25.4
6 $2
19.0
3 $6
1.42
$1
77.4
7 $6
0.82
$1
30.1
0 71
- Fem
ale
S
tand
ard
$143
.98
$251
.58
$70.
33
$203
.79
$69.
65
$149
.32
72 -M
ale
P
refe
rred
$138
.93
$242
.71
$67.
90
$196
.60
$67.
24
$144
.07
72-M
ale
S
tand
ard
$159
.47
$278
.82
$77.
78
$225
.80
$77.
03
$165
.38
72-F
emal
e
Pre
ferr
ed$1
29.3
7 $2
25.9
0 $6
3.30
$1
83.0
2 $6
2.69
$1
34.1
6 72
- Fem
ale
S
tand
ard
$148
.47
$259
.49
$72.
50
$210
.19
$71.
79
$153
.99
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
Page
4O
H81
077N
M20
Hum
anaM
edica
re Su
pple
men
t Are
a 1M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
FHi
gh
Dedu
ctib
le
Plan
FPl
an G
High
De
duct
ible
Pl
an G
Plan
N
73 -M
ale
P
refe
rred
$143
.54
$250
.81
$70.
12
$203
.16
$69.
44
$148
.86
73-M
ale
S
tand
ard
$164
.77
$288
.12
$80.
33
$233
.33
$79.
55
$170
.89
73-F
emal
e
Pre
ferr
ed$1
33.4
0 $2
32.9
9 $6
5.24
$1
88.7
6 $6
4.61
$1
38.3
4 73
- Fem
ale
S
tand
ard
$153
.12
$267
.65
$74.
73
$216
.77
$74.
01
$158
.80
74 -M
ale
P
refe
rred
$148
.30
$259
.18
$72.
41
$209
.94
$71.
71
$153
.80
74-M
ale
S
tand
ard
$170
.24
$297
.76
$82.
97
$241
.12
$82.
16
$176
.57
74-F
emal
e
Pre
ferr
ed$1
37.5
7 $2
40.3
2 $6
7.25
$1
94.6
8 $6
6.59
$1
42.6
7 74
- Fem
ale
S
tand
ard
$157
.90
$276
.07
$77.
04
$223
.58
$76.
29
$163
.77
75 -M
ale
P
refe
rred
$153
.23
$267
.83
$74.
78
$216
.93
$74.
05
$158
.90
75-M
ale
S
tand
ard
$175
.91
$307
.71
$85.
70
$249
.17
$84.
87
$182
.44
75-F
emal
e
Pre
ferr
ed$1
41.8
7 $2
47.8
7 $6
9.32
$2
00.8
0 $6
8.64
$1
47.1
2 75
- Fem
ale
S
tand
ard
$162
.85
$284
.76
$79.
42
$230
.60
$78.
64
$168
.90
76 -M
ale
P
refe
rred
$158
.31
$276
.78
$77.
23
$224
.16
$76.
48
$164
.19
76-M
ale
S
tand
ard
$181
.75
$317
.99
$88.
52
$257
.49
$87.
65
$188
.51
76-F
emal
e
Pre
ferr
ed$1
46.3
0 $2
55.6
6 $7
1.45
$2
07.0
9 $7
0.75
$1
51.7
3 76
- Fem
ale
S
tand
ard
$167
.94
$293
.71
$81.
87
$237
.85
$81.
07
$174
.18
77 -M
ale
P
refe
rred
$163
.57
$286
.03
$79.
76
$231
.63
$78.
99
$169
.65
77-M
ale
S
tand
ard
$187
.81
$328
.63
$91.
43
$266
.08
$90.
54
$194
.80
77-F
emal
e
Pre
ferr
ed$1
50.8
7 $2
63.7
1 $7
3.65
$2
13.5
9 $7
2.94
$1
56.4
7 77
- Fem
ale
S
tand
ard
$173
.20
$302
.97
$84.
40
$245
.33
$83.
58
$179
.64
78 -M
ale
P
refe
rred
$169
.00
$295
.58
$82.
38
$239
.37
$81.
58
$175
.28
78-M
ale
S
tand
ard
$194
.07
$339
.63
$94.
44
$274
.97
$93.
51
$201
.28
78-F
emal
e
Pre
ferr
ed$1
55.5
9 $2
71.9
9 $7
5.92
$2
20.3
0 $7
5.18
$1
61.3
7 78
- Fem
ale
S
tand
ard
$178
.62
$312
.49
$87.
01
$253
.04
$86.
16
$185
.27
79 -M
ale
P
refe
rred
$174
.63
$305
.47
$85.
09
$247
.36
$84.
25
$181
.12
79-M
ale
S
tand
ard
$200
.53
$350
.99
$97.
54
$284
.15
$96.
60
$207
.99
79-F
emal
e
Pre
ferr
ed$1
60.4
5 $2
80.5
5 $7
8.26
$2
27.2
1 $7
7.50
$1
66.4
1 79
- Fem
ale
S
tand
ard
$184
.22
$322
.33
$89.
70
$260
.99
$88.
83
$191
.08
80 -M
ale
P
refe
rred
$180
.43
$315
.67
$87.
88
$255
.61
$87.
02
$187
.15
80-M
ale
S
tand
ard
$207
.21
$362
.72
$100
.76
$293
.65
$99.
78
$214
.92
80-F
emal
e
Pre
ferr
ed$1
65.4
9 $2
89.3
8 $8
0.68
$2
34.3
5 $7
9.90
$1
71.6
2 80
- Fem
ale
S
tand
ard
$190
.00
$332
.49
$92.
48
$269
.21
$91.
58
$197
.07
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
5
Hum
anaM
edica
re Su
pple
men
t Are
a 1M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
FHi
gh
Dedu
ctib
le
Plan
FPl
an G
High
De
duct
ible
Pl
an G
Plan
N
81 -M
ale
P
refe
rred
$186
.44
$326
.23
$90.
77
$264
.15
$89.
88
$193
.38
81-M
ale
S
tand
ard
$214
.11
$374
.87
$104
.09
$303
.46
$103
.07
$222
.08
81-F
emal
e
Pre
ferr
ed$1
70.6
6 $2
98.4
9 $8
3.17
$2
41.7
1 $8
2.36
$1
77.0
0 81
- Fem
ale
S
tand
ard
$195
.96
$342
.95
$95.
35
$277
.67
$94.
41
$203
.25
82 -M
ale
P
refe
rred
$192
.65
$337
.15
$93.
76
$272
.97
$92.
84
$199
.82
82-M
ale
S
tand
ard
$221
.25
$387
.42
$107
.52
$313
.62
$106
.47
$229
.49
82-F
emal
e
Pre
ferr
ed$1
76.0
0 $3
07.8
8 $8
5.75
$2
49.3
1 $8
4.91
$1
82.5
4 82
- Fem
ale
S
tand
ard
$202
.11
$353
.77
$98.
31
$286
.41
$97.
35
$209
.64
83 -M
ale
P
refe
rred
$199
.07
$348
.42
$96.
85
$282
.08
$95.
90
$206
.47
83-M
ale
S
tand
ard
$228
.63
$400
.38
$111
.08
$324
.11
$109
.98
$237
.15
83-F
emal
e
Pre
ferr
ed$1
81.5
2 $3
17.5
9 $8
8.40
$2
57.1
4 $8
7.54
$1
88.2
7 83
- Fem
ale
S
tand
ard
$208
.45
$364
.92
$101
.36
$295
.43
$100
.37
$216
.21
84 -M
ale
P
refe
rred
$205
.69
$360
.08
$100
.04
$291
.52
$99.
06
$213
.36
84-M
ale
S
tand
ard
$236
.25
$413
.80
$114
.75
$334
.94
$113
.62
$245
.06
84-F
emal
e
Pre
ferr
ed$1
87.2
0 $3
27.5
8 $9
1.14
$2
65.2
3 $9
0.25
$1
94.1
7 84
- Fem
ale
S
tand
ard
$214
.99
$376
.42
$104
.51
$304
.71
$103
.48
$223
.00
85 -M
ale
P
refe
rred
$212
.55
$372
.15
$103
.34
$301
.26
$102
.33
$220
.47
85-M
ale
S
tand
ard
$244
.14
$427
.66
$118
.54
$346
.15
$117
.38
$253
.24
85-F
emal
e
Pre
ferr
ed$1
93.0
8 $3
37.9
0 $9
3.97
$2
73.5
8 $9
3.04
$2
00.2
7 85
- Fem
ale
S
tand
ard
$221
.73
$388
.29
$107
.76
$314
.31
$106
.71
$230
.00
86 -M
ale
P
refe
rred
$219
.64
$384
.58
$106
.75
$311
.33
$105
.70
$227
.83
86-M
ale
S
tand
ard
$252
.29
$441
.98
$122
.46
$357
.73
$121
.26
$261
.70
86-F
emal
e
Pre
ferr
ed$1
99.1
3 $3
48.5
4 $9
6.88
$2
82.1
8 $9
5.93
$2
06.5
5 86
- Fem
ale
S
tand
ard
$228
.70
$400
.53
$111
.11
$324
.21
$110
.02
$237
.23
87 -M
ale
P
refe
rred
$226
.97
$397
.47
$110
.27
$321
.74
$109
.19
$235
.43
87-M
ale
S
tand
ard
$260
.71
$456
.78
$126
.52
$369
.69
$125
.27
$270
.43
87-F
emal
e
Pre
ferr
ed$2
05.3
9 $3
59.5
2 $9
9.88
$2
91.0
7 $9
8.91
$2
13.0
3 87
- Fem
ale
S
tand
ard
$235
.89
$413
.15
$114
.57
$334
.43
$113
.45
$244
.68
88 -M
ale
P
refe
rred
$234
.54
$410
.77
$113
.91
$332
.50
$112
.80
$243
.28
88-M
ale
S
tand
ard
$269
.43
$472
.09
$130
.70
$382
.07
$129
.42
$279
.47
88-F
emal
e
Pre
ferr
ed$2
11.8
3 $3
70.8
6 $1
02.9
8 $3
00.2
2 $1
01.9
8 $2
19.7
1 88
- Fem
ale
S
tand
ard
$243
.31
$426
.18
$118
.14
$344
.96
$116
.97
$252
.38
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
Page
6O
H81
077N
M20
Hum
anaM
edica
re Su
pple
men
t Are
a 1M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
FHi
gh
Dedu
ctib
le
Plan
FPl
an G
High
De
duct
ible
Pl
an G
Plan
N
89 -M
ale
P
refe
rred
$242
.36
$424
.54
$117
.68
$343
.62
$116
.52
$251
.40
89-M
ale
S
tand
ard
$278
.42
$487
.92
$135
.04
$394
.86
$133
.71
$288
.81
89-F
emal
e
Pre
ferr
ed$2
18.4
8 $3
82.5
6 $1
06.1
9 $3
09.6
8 $1
05.1
5 $2
26.6
2 89
- Fem
ale
S
tand
ard
$250
.96
$439
.62
$121
.82
$355
.83
$120
.62
$260
.32
90 -M
ale
P
refe
rred
$250
.45
$438
.76
$121
.58
$355
.12
$120
.38
$259
.80
90-M
ale
S
tand
ard
$287
.72
$504
.26
$139
.51
$408
.09
$138
.14
$298
.46
90-F
emal
e
Pre
ferr
ed$2
25.3
4 $3
94.6
1 $1
09.4
9 $3
19.4
3 $1
08.4
1 $2
33.7
3 90
- Fem
ale
S
tand
ard
$258
.84
$453
.51
$125
.61
$367
.04
$124
.38
$268
.50
91 -M
ale
P
refe
rred
$258
.81
$453
.45
$125
.60
$367
.01
$124
.37
$268
.47
91-M
ale
S
tand
ard
$297
.33
$521
.17
$144
.14
$421
.75
$142
.72
$308
.44
91-F
emal
e
Pre
ferr
ed$2
32.4
1 $4
07.0
6 $1
12.9
0 $3
29.4
9 $1
11.7
9 $2
41.0
9 91
- Fem
ale
S
tand
ard
$266
.98
$467
.81
$129
.54
$378
.60
$128
.26
$276
.94
92 -M
ale
P
refe
rred
$267
.46
$468
.65
$129
.76
$379
.28
$128
.48
$277
.43
92-M
ale
S
tand
ard
$307
.27
$538
.64
$148
.92
$435
.88
$147
.45
$318
.75
92-F
emal
e
Pre
ferr
ed$2
39.7
2 $4
19.8
9 $1
16.4
1 $3
39.8
6 $1
15.2
7 $2
48.6
6 92
- Fem
ale
S
tand
ard
$275
.37
$482
.57
$133
.57
$390
.54
$132
.26
$285
.66
93 -M
ale
P
refe
rred
$276
.38
$484
.34
$134
.06
$391
.98
$132
.74
$286
.71
93-M
ale
S
tand
ard
$317
.55
$556
.70
$153
.87
$450
.48
$152
.35
$329
.41
93-F
emal
e
Pre
ferr
ed$2
47.2
5 $4
33.1
3 $1
20.0
4 $3
50.5
7 $1
18.8
5 $2
56.4
8 93
- Fem
ale
S
tand
ard
$284
.05
$497
.80
$137
.74
$402
.86
$136
.39
$294
.65
94 -M
ale
P
refe
rred
$285
.63
$500
.58
$138
.50
$405
.11
$137
.14
$296
.29
94-M
ale
S
tand
ard
$328
.16
$575
.37
$158
.98
$465
.57
$157
.42
$340
.43
94-F
emal
e
Pre
ferr
ed$2
55.0
2 $4
46.8
0 $1
23.7
7 $3
61.6
2 $1
22.5
7 $2
64.5
4 94
- Fem
ale
S
tand
ard
$292
.98
$513
.51
$142
.05
$415
.56
$140
.64
$303
.92
95 -M
ale
P
refe
rred
$295
.18
$517
.36
$143
.10
$418
.67
$141
.69
$306
.19
95-M
ale
S
tand
ard
$339
.15
$594
.68
$164
.26
$481
.18
$162
.65
$351
.82
95-F
emal
e
Pre
ferr
ed$2
63.0
5 $4
60.8
9 $1
27.6
4 $3
73.0
1 $1
26.3
8 $2
72.8
6 95
- Fem
ale
S
tand
ard
$302
.21
$529
.73
$146
.49
$428
.67
$145
.04
$313
.49
96 -M
ale
P
refe
rred
$305
.04
$534
.71
$147
.85
$432
.70
$146
.39
$316
.43
96-M
ale
S
tand
ard
$350
.49
$614
.61
$169
.72
$497
.30
$168
.05
$363
.60
96-F
emal
e
Pre
ferr
ed$2
71.3
2 $4
75.4
3 $1
31.6
2 $3
84.7
7 $1
30.3
3 $2
81.4
5 96
- Fem
ale
S
tand
ard
$311
.72
$546
.45
$151
.06
$442
.19
$149
.58
$323
.36
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
7
Hum
anaM
edica
re Su
pple
men
t Are
a 1M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
FHi
gh
Dedu
ctib
le
Plan
FPl
an G
High
De
duct
ible
Pl
an G
Plan
N
97 -M
ale
P
refe
rred
$315
.23
$552
.63
$152
.76
$447
.19
$151
.25
$327
.01
97-M
ale
S
tand
ard
$362
.22
$635
.22
$175
.37
$513
.96
$173
.64
$375
.77
97-F
emal
e
Pre
ferr
ed$2
79.8
6 $4
90.4
5 $1
35.7
2 $3
96.9
1 $1
34.3
9 $2
90.3
0 97
- Fem
ale
S
tand
ard
$321
.53
$563
.70
$155
.78
$456
.14
$154
.26
$333
.54
98 -M
ale
P
refe
rred
$325
.77
$571
.16
$157
.83
$462
.18
$156
.27
$337
.95
98-M
ale
S
tand
ard
$374
.34
$656
.54
$181
.20
$531
.20
$179
.41
$388
.34
98-F
emal
e
Pre
ferr
ed$2
88.6
6 $5
05.9
2 $1
39.9
7 $4
09.4
2 $1
38.5
8 $2
99.4
4 98
- Fem
ale
S
tand
ard
$331
.65
$581
.51
$160
.66
$470
.54
$159
.08
$344
.06
99 +-
Mal
e
Pre
ferr
ed$3
36.6
7 $5
90.3
3 $1
63.0
8 $4
77.6
6 $1
61.4
6 $3
49.2
6 99
-Mal
e
Sta
ndar
d$3
86.8
7 $6
78.5
7 $1
87.2
3 $5
49.0
1 $1
85.3
8 $4
01.3
4 99
+-Fe
mal
e
Pre
ferr
ed$2
97.7
3 $5
21.9
0 $1
44.3
3 $4
22.3
3 $1
42.9
2 $3
08.8
6 99
- Fem
ale
S
tand
ard
$342
.10
$599
.86
$165
.69
$485
.38
$164
.05
$354
.89
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.
Page
8O
H81
077N
M20
Hum
anaM
edica
re Su
pple
men
t Are
a 2M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
65 -M
ale
P
refe
rred
$106
.43
$185
.58
$52.
26
$150
.42
$51.
76
$110
.36
99-M
ale
S
tand
ard
$122
.09
$213
.11
$59.
80
$172
.69
$59.
22
$126
.61
65-F
emal
e
Pre
ferr
ed$1
00.4
4 $1
75.0
5 $4
9.38
$1
41.9
1 $4
8.91
$1
04.1
4 99
- Fem
ale
S
tand
ard
$115
.21
$201
.01
$56.
49
$162
.90
$55.
94
$119
.47
66 -M
ale
P
refe
rred
$109
.95
$191
.76
$53.
95
$155
.42
$53.
43
$114
.00
99-M
ale
S
tand
ard
$126
.14
$220
.22
$61.
75
$178
.43
$61.
15
$130
.81
66-F
emal
e
Pre
ferr
ed$1
03.5
6 $1
80.5
4 $5
0.88
$1
46.3
4 $5
0.39
$1
07.3
8 99
- Fem
ale
S
tand
ard
$118
.80
$207
.32
$58.
21
$168
.00
$57.
65
$123
.19
67 -M
ale
P
refe
rred
$113
.58
$198
.14
$55.
70
$160
.59
$55.
17
$117
.77
99-M
ale
S
tand
ard
$130
.32
$227
.57
$63.
76
$184
.37
$63.
14
$135
.14
67-F
emal
e
Pre
ferr
ed$1
06.7
8 $1
86.2
0 $5
2.43
$1
50.9
2 $5
1.93
$1
10.7
2 99
- Fem
ale
S
tand
ard
$122
.50
$213
.83
$59.
99
$173
.26
$59.
42
$127
.03
68 -M
ale
P
refe
rred
$117
.33
$204
.74
$57.
51
$165
.92
$56.
95
$121
.67
99-M
ale
S
tand
ard
$134
.63
$235
.16
$65.
84
$190
.51
$65.
20
$139
.62
68-F
emal
e
Pre
ferr
ed$1
10.1
1 $1
92.0
4 $5
4.03
$1
55.6
4 $5
3.51
$1
14.1
7 99
- Fem
ale
S
tand
ard
$126
.32
$220
.54
$61.
83
$178
.69
$61.
23
$130
.99
69 -M
ale
P
refe
rred
$121
.22
$211
.57
$59.
38
$171
.43
$58.
80
$125
.70
99-M
ale
S
tand
ard
$139
.10
$243
.00
$67.
98
$196
.85
$67.
32
$144
.25
69-F
emal
e
Pre
ferr
ed$1
13.5
2 $1
98.0
5 $5
5.68
$1
60.5
1 $5
5.14
$1
17.7
2 99
- Fem
ale
S
tand
ard
$130
.26
$227
.47
$63.
73
$184
.29
$63.
11
$135
.08
70 -M
ale
P
refe
rred
$125
.22
$218
.62
$61.
31
$177
.14
$60.
72
$129
.86
99-M
ale
S
tand
ard
$143
.71
$251
.12
$70.
20
$203
.41
$69.
52
$149
.04
70-F
emal
e
Pre
ferr
ed$1
17.0
6 $2
04.2
7 $5
7.38
$1
65.5
4 $5
6.83
$1
21.3
9 99
- Fem
ale
S
tand
ard
$134
.32
$234
.61
$65.
68
$190
.07
$65.
05
$139
.30
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
9
Hum
anaM
edica
re Su
pple
men
t Are
a 2M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
71 -M
ale
P
refe
rred
$129
.37
$225
.92
$63.
30
$183
.04
$62.
69
$134
.16
99-M
ale
S
tand
ard
$148
.48
$259
.50
$72.
50
$210
.19
$71.
80
$153
.99
71-F
emal
e
Pre
ferr
ed$1
20.7
1 $2
10.6
8 $5
9.13
$1
70.7
2 $5
8.56
$1
25.1
7 99
- Fem
ale
S
tand
ard
$138
.52
$241
.98
$67.
70
$196
.03
$67.
05
$143
.65
72 -M
ale
P
refe
rred
$133
.66
$233
.45
$65.
37
$189
.12
$64.
73
$138
.61
99-M
ale
S
tand
ard
$153
.41
$268
.17
$74.
87
$217
.19
$74.
14
$159
.10
72-F
emal
e
Pre
ferr
ed$1
24.4
7 $2
17.2
9 $6
0.94
$1
76.0
6 $6
0.36
$1
29.0
8 99
- Fem
ale
S
tand
ard
$142
.84
$249
.59
$69.
79
$202
.18
$69.
11
$148
.14
73 -M
ale
P
refe
rred
$138
.10
$241
.24
$67.
50
$195
.42
$66.
85
$143
.21
99-M
ale
S
tand
ard
$158
.51
$277
.12
$77.
32
$224
.43
$76.
57
$164
.39
73-F
emal
e
Pre
ferr
ed$1
28.3
5 $2
24.1
1 $6
2.81
$1
81.5
8 $6
2.20
$1
33.1
0 99
- Fem
ale
S
tand
ard
$147
.31
$257
.43
$71.
93
$208
.51
$71.
24
$152
.77
74 -M
ale
P
refe
rred
$142
.67
$249
.29
$69.
70
$201
.94
$69.
03
$147
.96
99-M
ale
S
tand
ard
$163
.77
$286
.38
$79.
86
$231
.92
$79.
08
$169
.86
74-F
emal
e
Pre
ferr
ed$1
32.3
6 $2
31.1
5 $6
4.74
$1
87.2
7 $6
4.11
$1
37.2
6 99
- Fem
ale
S
tand
ard
$151
.90
$265
.53
$74.
15
$215
.06
$73.
43
$157
.55
75 -M
ale
P
refe
rred
$147
.41
$257
.61
$71.
98
$208
.66
$71.
28
$152
.87
99-M
ale
S
tand
ard
$169
.22
$295
.95
$82.
48
$239
.66
$81.
68
$175
.50
75-F
emal
e
Pre
ferr
ed$1
36.4
9 $2
38.4
1 $6
6.73
$1
93.1
5 $6
6.08
$1
41.5
4 99
- Fem
ale
S
tand
ard
$156
.66
$273
.88
$76.
44
$221
.81
$75.
69
$162
.48
76 -M
ale
P
refe
rred
$152
.30
$266
.21
$74.
34
$215
.62
$73.
62
$157
.95
99-M
ale
S
tand
ard
$174
.84
$305
.84
$85.
19
$247
.66
$84.
36
$181
.34
76-F
emal
e
Pre
ferr
ed$1
40.7
5 $2
45.9
0 $6
8.78
$1
99.2
0 $6
8.11
$1
45.9
7 99
- Fem
ale
S
tand
ard
$161
.56
$282
.49
$78.
80
$228
.78
$78.
03
$167
.56
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
Page
10
OH
8107
7NM
20
Hum
anaM
edica
re Su
pple
men
t Are
a 2M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
77 -M
ale
P
refe
rred
$157
.36
$275
.11
$76.
77
$222
.80
$76.
03
$163
.20
99-M
ale
S
tand
ard
$180
.66
$316
.07
$87.
99
$255
.92
$87.
13
$187
.38
77-F
emal
e
Pre
ferr
ed$1
45.1
4 $2
53.6
4 $7
0.89
$2
05.4
5 $7
0.21
$1
50.5
3 99
- Fem
ale
S
tand
ard
$166
.62
$291
.39
$81.
23
$235
.97
$80.
44
$172
.81
78 -M
ale
P
refe
rred
$162
.58
$284
.29
$79.
29
$230
.24
$78.
52
$168
.62
99-M
ale
S
tand
ard
$186
.68
$326
.64
$90.
88
$264
.47
$89.
99
$193
.62
78-F
emal
e
Pre
ferr
ed$1
49.6
8 $2
61.6
1 $7
3.08
$2
11.9
0 $7
2.37
$1
55.2
4 99
- Fem
ale
S
tand
ard
$171
.83
$300
.55
$83.
74
$243
.38
$82.
92
$178
.22
79 -M
ale
P
refe
rred
$167
.99
$293
.80
$81.
89
$237
.92
$81.
09
$174
.23
99-M
ale
S
tand
ard
$192
.89
$337
.57
$93.
87
$273
.30
$92.
96
$200
.07
79-F
emal
e
Pre
ferr
ed$1
54.3
6 $2
69.8
4 $7
5.33
$2
18.5
5 $7
4.60
$1
60.0
9 99
- Fem
ale
S
tand
ard
$177
.21
$310
.01
$86.
33
$251
.03
$85.
49
$183
.81
80 -M
ale
P
refe
rred
$173
.57
$303
.61
$84.
58
$245
.86
$83.
75
$180
.03
99-M
ale
S
tand
ard
$199
.32
$348
.85
$96.
96
$282
.43
$96.
02
$206
.73
80-F
emal
e
Pre
ferr
ed$1
59.2
0 $2
78.3
3 $7
7.65
$2
25.4
1 $7
6.90
$1
65.1
0 99
- Fem
ale
S
tand
ard
$182
.77
$319
.78
$89.
00
$258
.93
$88.
13
$189
.57
81 -M
ale
P
refe
rred
$179
.35
$313
.76
$87.
36
$254
.07
$86.
50
$186
.02
99-M
ale
S
tand
ard
$205
.95
$360
.53
$100
.16
$291
.87
$99.
18
$213
.62
81-F
emal
e
Pre
ferr
ed$1
64.1
7 $2
87.0
9 $8
0.05
$2
32.4
9 $7
9.27
$1
70.2
7 99
- Fem
ale
S
tand
ard
$188
.50
$329
.84
$91.
76
$267
.07
$90.
86
$195
.51
82 -M
ale
P
refe
rred
$185
.32
$324
.26
$90.
23
$262
.55
$89.
35
$192
.21
99-M
ale
S
tand
ard
$212
.82
$372
.60
$103
.46
$301
.63
$102
.45
$220
.74
82-F
emal
e
Pre
ferr
ed$1
69.3
1 $2
96.1
2 $8
2.53
$2
39.8
0 $8
1.72
$1
75.6
0 99
- Fem
ale
S
tand
ard
$194
.41
$340
.24
$94.
61
$275
.47
$93.
68
$201
.65
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
11
Hum
anaM
edica
re Su
pple
men
t Are
a 2M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
83 -M
ale
P
refe
rred
$191
.49
$335
.10
$93.
20
$271
.31
$92.
29
$198
.61
99-M
ale
S
tand
ard
$219
.91
$385
.06
$106
.88
$311
.72
$105
.83
$228
.11
83-F
emal
e
Pre
ferr
ed$1
74.6
2 $3
05.4
5 $8
5.08
$2
47.3
3 $8
4.25
$1
81.1
1 99
- Fem
ale
S
tand
ard
$200
.51
$350
.96
$97.
54
$284
.14
$96.
59
$207
.97
84 -M
ale
P
refe
rred
$197
.86
$346
.31
$96.
27
$280
.38
$95.
33
$205
.23
99-M
ale
S
tand
ard
$227
.24
$397
.96
$110
.41
$322
.13
$109
.33
$235
.71
84-F
emal
e
Pre
ferr
ed$1
80.0
8 $3
15.0
6 $8
7.71
$2
55.1
1 $8
6.86
$1
86.7
8 99
- Fem
ale
S
tand
ard
$206
.80
$362
.02
$100
.57
$293
.07
$99.
58
$214
.50
85 -M
ale
P
refe
rred
$204
.45
$357
.91
$99.
44
$289
.75
$98.
47
$212
.07
99-M
ale
S
tand
ard
$234
.83
$411
.29
$114
.06
$332
.91
$112
.94
$243
.58
85-F
emal
e
Pre
ferr
ed$1
85.7
3 $3
24.9
8 $9
0.43
$2
63.1
3 $8
9.54
$1
92.6
4 99
- Fem
ale
S
tand
ard
$213
.28
$373
.43
$103
.69
$302
.30
$102
.68
$221
.23
86 -M
ale
P
refe
rred
$211
.27
$369
.87
$102
.72
$299
.43
$101
.71
$219
.14
99-M
ale
S
tand
ard
$242
.66
$425
.06
$117
.83
$344
.05
$116
.67
$251
.71
86-F
emal
e
Pre
ferr
ed$1
91.5
5 $3
35.2
1 $9
3.23
$2
71.4
0 $9
2.32
$1
98.6
8 99
- Fem
ale
S
tand
ard
$219
.98
$385
.20
$106
.91
$311
.82
$105
.87
$228
.18
87 -M
ale
P
refe
rred
$218
.32
$382
.26
$106
.11
$309
.44
$105
.07
$226
.45
99-M
ale
S
tand
ard
$250
.76
$439
.29
$121
.73
$355
.55
$120
.53
$260
.11
87-F
emal
e
Pre
ferr
ed$1
97.5
7 $3
45.7
7 $9
6.12
$2
79.9
5 $9
5.18
$2
04.9
1 99
- Fem
ale
S
tand
ard
$226
.89
$397
.34
$110
.24
$321
.64
$109
.16
$235
.35
88 -M
ale
P
refe
rred
$225
.60
$395
.05
$109
.61
$319
.79
$108
.54
$234
.00
99-M
ale
S
tand
ard
$259
.14
$454
.01
$125
.75
$367
.45
$124
.52
$268
.80
88-F
emal
e
Pre
ferr
ed$2
03.7
6 $3
56.6
7 $9
9.10
$2
88.7
5 $9
8.13
$2
11.3
4 99
- Fem
ale
S
tand
ard
$234
.03
$409
.87
$113
.67
$331
.77
$112
.55
$242
.75
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
Page
12
OH
8107
7NM
20
Hum
anaM
edica
re Su
pple
men
t Are
a 2M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
89 -M
ale
P
refe
rred
$233
.12
$408
.29
$113
.23
$330
.48
$112
.12
$241
.81
99-M
ale
S
tand
ard
$267
.79
$469
.23
$129
.92
$379
.75
$128
.64
$277
.78
89-F
emal
e
Pre
ferr
ed$2
10.1
5 $3
67.9
2 $1
02.1
8 $2
97.8
5 $1
01.1
8 $2
17.9
8 99
- Fem
ale
S
tand
ard
$241
.38
$422
.79
$117
.21
$342
.22
$116
.06
$250
.38
90 -M
ale
P
refe
rred
$240
.89
$421
.96
$116
.98
$341
.54
$115
.83
$249
.88
99-M
ale
S
tand
ard
$276
.73
$484
.94
$134
.22
$392
.47
$132
.90
$287
.06
90-F
emal
e
Pre
ferr
ed$2
16.7
5 $3
79.5
1 $1
05.3
6 $3
07.2
2 $1
04.3
2 $2
24.8
2 99
- Fem
ale
S
tand
ard
$248
.96
$436
.14
$120
.86
$353
.00
$119
.67
$258
.25
91 -M
ale
P
refe
rred
$248
.93
$436
.09
$120
.85
$352
.97
$119
.66
$258
.22
99-M
ale
S
tand
ard
$285
.97
$501
.20
$138
.67
$405
.61
$137
.31
$296
.65
91-F
emal
e
Pre
ferr
ed$2
23.5
5 $3
91.4
8 $1
08.6
3 $3
16.8
9 $1
07.5
7 $2
31.8
9 99
- Fem
ale
S
tand
ard
$256
.79
$449
.89
$124
.63
$364
.12
$123
.40
$266
.37
92 -M
ale
P
refe
rred
$257
.25
$450
.70
$124
.85
$364
.77
$123
.62
$266
.84
99-M
ale
S
tand
ard
$295
.53
$518
.00
$143
.27
$419
.19
$141
.86
$306
.57
92-F
emal
e
Pre
ferr
ed$2
30.5
8 $4
03.8
2 $1
12.0
1 $3
26.8
7 $1
10.9
1 $2
39.1
7 99
- Fem
ale
S
tand
ard
$264
.86
$464
.09
$128
.51
$375
.60
$127
.25
$274
.75
93 -M
ale
P
refe
rred
$265
.83
$465
.79
$128
.98
$376
.98
$127
.71
$275
.76
99-M
ale
S
tand
ard
$305
.41
$535
.37
$148
.03
$433
.23
$146
.57
$316
.82
93-F
emal
e
Pre
ferr
ed$2
37.8
2 $4
16.5
5 $1
15.5
0 $3
37.1
6 $1
14.3
6 $2
46.6
9 99
- Fem
ale
S
tand
ard
$273
.20
$478
.73
$132
.52
$387
.44
$131
.22
$283
.39
94 -M
ale
P
refe
rred
$274
.72
$481
.40
$133
.25
$389
.61
$131
.94
$284
.97
99-M
ale
S
tand
ard
$315
.62
$553
.32
$152
.94
$447
.74
$151
.44
$327
.41
94-F
emal
e
Pre
ferr
ed$2
45.2
9 $4
29.6
9 $1
19.0
9 $3
47.7
9 $1
17.9
3 $2
54.4
4 99
- Fem
ale
S
tand
ard
$281
.79
$493
.84
$136
.66
$399
.65
$135
.31
$292
.31
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
13
Hum
anaM
edica
re Su
pple
men
t Are
a 2M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
95 -M
ale
P
refe
rred
$283
.90
$497
.54
$137
.67
$402
.64
$136
.32
$294
.49
99-M
ale
S
tand
ard
$326
.18
$571
.88
$158
.02
$462
.75
$156
.47
$338
.37
95-F
emal
e
Pre
ferr
ed$2
53.0
1 $4
43.2
4 $1
22.8
1 $3
58.7
4 $1
21.6
0 $2
62.4
4 99
- Fem
ale
S
tand
ard
$290
.66
$509
.43
$140
.93
$412
.26
$139
.54
$301
.51
96 -M
ale
P
refe
rred
$293
.38
$514
.22
$142
.24
$416
.13
$140
.84
$304
.34
99-M
ale
S
tand
ard
$337
.09
$591
.05
$163
.27
$478
.25
$161
.66
$349
.69
96-F
emal
e
Pre
ferr
ed$2
60.9
6 $4
57.2
2 $1
26.6
3 $3
70.0
5 $1
25.3
9 $2
70.7
0 99
- Fem
ale
S
tand
ard
$299
.81
$525
.51
$145
.33
$425
.26
$143
.90
$311
.00
97 -M
ale
P
refe
rred
$303
.18
$531
.45
$146
.96
$430
.07
$145
.51
$314
.51
99-M
ale
S
tand
ard
$348
.37
$610
.87
$168
.70
$494
.27
$167
.04
$361
.39
97-F
emal
e
Pre
ferr
ed$2
69.1
7 $4
71.6
6 $1
30.5
8 $3
81.7
2 $1
29.3
0 $2
79.2
1 99
- Fem
ale
S
tand
ard
$309
.24
$542
.10
$149
.87
$438
.67
$148
.40
$320
.79
98 -M
ale
P
refe
rred
$313
.32
$549
.27
$151
.84
$444
.48
$150
.34
$325
.03
99-M
ale
S
tand
ard
$360
.02
$631
.37
$174
.31
$510
.85
$172
.59
$373
.48
98-F
emal
e
Pre
ferr
ed$2
77.6
3 $4
86.5
4 $1
34.6
6 $3
93.7
5 $1
33.3
3 $2
88.0
0 99
- Fem
ale
S
tand
ard
$318
.97
$559
.22
$154
.56
$452
.52
$153
.04
$330
.90
99 +-
Mal
e
Pre
ferr
ed$3
23.8
0 $5
67.7
0 $1
56.8
8 $4
59.3
7 $1
55.3
3 $3
35.9
0 99
-Mal
e
Sta
ndar
d$3
72.0
7 $6
52.5
5 $1
80.1
1 $5
27.9
7 $1
78.3
3 $3
85.9
8 99
+-Fe
mal
e
Pre
ferr
ed$2
86.3
6 $5
01.9
0 $1
38.8
6 $4
06.1
6 $1
37.5
0 $2
97.0
6 99
- Fem
ale
S
tand
ard
$329
.02
$576
.87
$159
.39
$466
.79
$157
.82
$341
.32
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.
Page
14
OH
8107
7NM
20
Hum
anaM
edica
re Su
pple
men
t Are
a 3M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
65 -M
ale
P
refe
rred
$103
.30
$180
.07
$50.
75
$145
.97
$50.
27
$107
.11
99-M
ale
S
tand
ard
$118
.49
$206
.78
$58.
07
$167
.57
$57.
50
$122
.87
65-F
emal
e
Pre
ferr
ed$9
7.49
$1
69.8
6 $4
7.96
$1
37.7
1 $4
7.50
$1
01.0
8 99
- Fem
ale
S
tand
ard
$111
.81
$195
.04
$54.
86
$158
.07
$54.
32
$115
.95
66 -M
ale
P
refe
rred
$106
.71
$186
.07
$52.
39
$150
.82
$51.
89
$110
.64
99-M
ale
S
tand
ard
$122
.42
$213
.67
$59.
96
$173
.14
$59.
38
$126
.95
66-F
emal
e
Pre
ferr
ed$1
00.5
1 $1
75.1
8 $4
9.41
$1
42.0
1 $4
8.94
$1
04.2
2 99
- Fem
ale
S
tand
ard
$115
.30
$201
.16
$56.
52
$163
.02
$55.
98
$119
.55
67 -M
ale
P
refe
rred
$110
.23
$192
.26
$54.
09
$155
.83
$53.
57
$114
.30
99-M
ale
S
tand
ard
$126
.47
$220
.80
$61.
91
$178
.90
$61.
31
$131
.15
67-F
emal
e
Pre
ferr
ed$1
03.6
4 $1
80.6
7 $5
0.92
$1
46.4
5 $5
0.43
$1
07.4
6 99
- Fem
ale
S
tand
ard
$118
.89
$207
.48
$58.
25
$168
.12
$57.
70
$123
.28
68 -M
ale
P
refe
rred
$113
.87
$198
.66
$55.
84
$161
.00
$55.
30
$118
.08
99-M
ale
S
tand
ard
$130
.65
$228
.17
$63.
92
$184
.85
$63.
30
$135
.49
68-F
emal
e
Pre
ferr
ed$1
06.8
7 $1
86.3
4 $5
2.47
$1
51.0
3 $5
1.96
$1
10.8
0 99
- Fem
ale
S
tand
ard
$122
.59
$213
.98
$60.
04
$173
.39
$59.
45
$127
.12
69 -M
ale
P
refe
rred
$117
.64
$205
.28
$57.
66
$166
.35
$57.
10
$121
.99
99-M
ale
S
tand
ard
$134
.99
$235
.77
$66.
00
$191
.00
$65.
36
$139
.98
69-F
emal
e
Pre
ferr
ed$1
10.1
7 $1
92.1
7 $5
4.07
$1
55.7
5 $5
3.55
$1
14.2
5 99
- Fem
ale
S
tand
ard
$126
.41
$220
.71
$61.
88
$178
.82
$61.
28
$131
.09
70 -M
ale
P
refe
rred
$121
.52
$212
.12
$59.
53
$171
.89
$58.
96
$126
.02
99-M
ale
S
tand
ard
$139
.46
$243
.65
$68.
15
$197
.37
$67.
49
$144
.63
70-F
emal
e
Pre
ferr
ed$1
13.6
1 $1
98.2
0 $5
5.72
$1
60.6
3 $5
5.19
$1
17.8
1 99
- Fem
ale
S
tand
ard
$130
.35
$227
.63
$63.
77
$184
.43
$63.
16
$135
.18
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
15
Hum
anaM
edica
re Su
pple
men
t Are
a 3M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
71 -M
ale
P
refe
rred
$125
.55
$219
.20
$61.
46
$177
.61
$60.
87
$130
.20
99-M
ale
S
tand
ard
$144
.09
$251
.78
$70.
39
$203
.94
$69.
71
$149
.43
71-F
emal
e
Pre
ferr
ed$1
17.1
5 $2
04.4
2 $5
7.42
$1
65.6
6 $5
6.86
$1
21.4
7 99
- Fem
ale
S
tand
ard
$134
.42
$234
.78
$65.
73
$190
.21
$65.
10
$139
.40
72 -M
ale
P
refe
rred
$129
.71
$226
.51
$63.
47
$183
.51
$62.
85
$134
.51
99-M
ale
S
tand
ard
$148
.87
$260
.18
$72.
68
$210
.73
$71.
98
$154
.39
72-F
emal
e
Pre
ferr
ed$1
20.8
0 $2
10.8
3 $5
9.17
$1
70.8
4 $5
8.61
$1
25.2
7 99
- Fem
ale
S
tand
ard
$138
.61
$242
.16
$67.
76
$196
.17
$67.
10
$143
.76
73 -M
ale
P
refe
rred
$134
.02
$234
.06
$65.
54
$189
.62
$64.
90
$138
.97
99-M
ale
S
tand
ard
$153
.81
$268
.87
$75.
06
$217
.76
$74.
33
$159
.52
73-F
emal
e
Pre
ferr
ed$1
24.5
6 $2
17.4
5 $6
0.99
$1
76.1
9 $6
0.39
$1
29.1
7 99
- Fem
ale
S
tand
ard
$142
.95
$249
.77
$69.
83
$202
.31
$69.
16
$148
.25
74 -M
ale
P
refe
rred
$138
.45
$241
.87
$67.
67
$195
.94
$67.
02
$143
.58
99-M
ale
S
tand
ard
$158
.92
$277
.85
$77.
52
$225
.02
$76.
77
$164
.82
74-F
emal
e
Pre
ferr
ed$1
28.4
5 $2
24.2
8 $6
2.86
$1
81.7
1 $6
2.25
$1
33.2
0 99
- Fem
ale
S
tand
ard
$147
.40
$257
.62
$71.
99
$208
.67
$71.
29
$152
.88
75 -M
ale
P
refe
rred
$143
.05
$249
.94
$69.
88
$202
.46
$69.
20
$148
.34
99-M
ale
S
tand
ard
$164
.20
$287
.13
$80.
07
$232
.53
$79.
29
$170
.30
75-F
emal
e
Pre
ferr
ed$1
32.4
6 $2
31.3
2 $6
4.79
$1
87.4
2 $6
4.16
$1
37.3
5 99
- Fem
ale
S
tand
ard
$152
.02
$265
.72
$74.
21
$215
.22
$73.
48
$157
.67
76 -M
ale
P
refe
rred
$147
.79
$258
.28
$72.
17
$209
.21
$71.
47
$153
.27
99-M
ale
S
tand
ard
$169
.65
$296
.72
$82.
69
$240
.29
$81.
89
$175
.96
76-F
emal
e
Pre
ferr
ed$1
36.5
9 $2
38.5
8 $6
6.78
$1
93.2
8 $6
6.13
$1
41.6
5 99
- Fem
ale
S
tand
ard
$156
.77
$274
.08
$76.
50
$221
.98
$75.
75
$162
.59
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
Page
16
OH
8107
7NM
20
Hum
anaM
edica
re Su
pple
men
t Are
a 3M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
77 -M
ale
P
refe
rred
$152
.70
$266
.92
$74.
53
$216
.18
$73.
81
$158
.36
99-M
ale
S
tand
ard
$175
.30
$306
.65
$85.
41
$248
.30
$84.
58
$181
.82
77-F
emal
e
Pre
ferr
ed$1
40.8
5 $2
46.0
9 $6
8.82
$1
99.3
5 $6
8.16
$1
46.0
7 99
- Fem
ale
S
tand
ard
$161
.68
$282
.71
$78.
85
$228
.95
$78.
09
$167
.69
78 -M
ale
P
refe
rred
$157
.76
$275
.82
$76.
97
$223
.39
$76.
22
$163
.62
99-M
ale
S
tand
ard
$181
.14
$316
.90
$88.
21
$256
.60
$87.
35
$187
.87
78-F
emal
e
Pre
ferr
ed$1
45.2
5 $2
53.8
2 $7
0.95
$2
05.6
0 $7
0.26
$1
50.6
4 99
- Fem
ale
S
tand
ard
$166
.74
$291
.59
$81.
29
$236
.14
$80.
49
$172
.93
79 -M
ale
P
refe
rred
$163
.01
$285
.05
$79.
49
$230
.84
$78.
72
$169
.06
99-M
ale
S
tand
ard
$187
.16
$327
.50
$91.
11
$265
.16
$90.
23
$194
.13
79-F
emal
e
Pre
ferr
ed$1
49.7
9 $2
61.8
0 $7
3.13
$2
12.0
5 $7
2.42
$1
55.3
5 99
- Fem
ale
S
tand
ard
$171
.95
$300
.77
$83.
80
$243
.56
$82.
99
$178
.36
80 -M
ale
P
refe
rred
$168
.42
$294
.56
$82.
10
$238
.54
$81.
30
$174
.69
99-M
ale
S
tand
ard
$193
.40
$338
.44
$94.
11
$274
.02
$93.
20
$200
.59
80-F
emal
e
Pre
ferr
ed$1
54.4
8 $2
70.0
4 $7
5.38
$2
18.7
1 $7
4.65
$1
60.2
1 99
- Fem
ale
S
tand
ard
$177
.35
$310
.25
$86.
39
$251
.22
$85.
55
$183
.94
81 -M
ale
P
refe
rred
$174
.03
$304
.41
$84.
80
$246
.51
$83.
97
$180
.50
99-M
ale
S
tand
ard
$199
.83
$349
.77
$97.
22
$283
.17
$96.
26
$207
.27
81-F
emal
e
Pre
ferr
ed$1
59.3
0 $2
78.5
4 $7
7.71
$2
25.5
8 $7
6.95
$1
65.2
2 99
- Fem
ale
S
tand
ard
$182
.91
$320
.00
$89.
07
$259
.12
$88.
19
$189
.70
82 -M
ale
P
refe
rred
$179
.82
$314
.59
$87.
58
$254
.73
$86.
73
$186
.50
99-M
ale
S
tand
ard
$206
.50
$361
.48
$100
.42
$292
.64
$99.
44
$214
.18
82-F
emal
e
Pre
ferr
ed$1
64.2
9 $2
87.3
0 $8
0.11
$2
32.6
7 $7
9.33
$1
70.3
9 99
- Fem
ale
S
tand
ard
$188
.64
$330
.09
$91.
83
$267
.27
$90.
93
$195
.66
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
17
Hum
anaM
edica
re Su
pple
men
t Are
a 3M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
83 -M
ale
P
refe
rred
$185
.81
$325
.11
$90.
46
$263
.23
$89.
58
$192
.71
99-M
ale
S
tand
ard
$213
.37
$373
.57
$103
.73
$302
.43
$102
.72
$221
.33
83-F
emal
e
Pre
ferr
ed$1
69.4
4 $2
96.3
5 $8
2.59
$2
39.9
7 $8
1.78
$1
75.7
4 99
- Fem
ale
S
tand
ard
$194
.55
$340
.49
$94.
67
$275
.68
$93.
75
$201
.79
84 -M
ale
P
refe
rred
$191
.98
$335
.98
$93.
44
$272
.03
$92.
53
$199
.13
99-M
ale
S
tand
ard
$220
.48
$386
.08
$107
.16
$312
.53
$106
.11
$228
.70
84-F
emal
e
Pre
ferr
ed$1
74.7
4 $3
05.6
7 $8
5.14
$2
47.5
2 $8
4.31
$1
81.2
4 99
- Fem
ale
S
tand
ard
$200
.66
$351
.22
$97.
61
$284
.34
$96.
65
$208
.13
85 -M
ale
P
refe
rred
$198
.38
$347
.23
$96.
52
$281
.12
$95.
58
$205
.77
99-M
ale
S
tand
ard
$227
.85
$399
.01
$110
.70
$322
.98
$109
.61
$236
.33
85-F
emal
e
Pre
ferr
ed$1
80.2
2 $3
15.2
9 $8
7.78
$2
55.3
0 $8
6.91
$1
86.9
2 99
- Fem
ale
S
tand
ard
$206
.94
$362
.29
$100
.64
$293
.29
$99.
66
$214
.65
86 -M
ale
P
refe
rred
$204
.99
$358
.83
$99.
70
$290
.51
$98.
72
$212
.63
99-M
ale
S
tand
ard
$235
.44
$412
.37
$114
.36
$333
.79
$113
.23
$244
.22
86-F
emal
e
Pre
ferr
ed$1
85.8
6 $3
25.2
1 $9
0.49
$2
63.3
2 $8
9.61
$1
92.7
8 99
- Fem
ale
S
tand
ard
$213
.44
$373
.70
$103
.76
$302
.53
$102
.75
$221
.39
87 -M
ale
P
refe
rred
$211
.83
$370
.85
$102
.99
$300
.22
$101
.98
$219
.72
99-M
ale
S
tand
ard
$243
.30
$426
.17
$118
.14
$344
.94
$116
.97
$252
.37
87-F
emal
e
Pre
ferr
ed$1
91.7
0 $3
35.4
6 $9
3.30
$2
71.6
1 $9
2.38
$1
98.8
2 99
- Fem
ale
S
tand
ard
$220
.14
$385
.48
$106
.99
$312
.05
$105
.95
$228
.35
88 -M
ale
P
refe
rred
$218
.89
$383
.26
$106
.38
$310
.26
$105
.34
$227
.04
99-M
ale
S
tand
ard
$251
.43
$440
.45
$122
.04
$356
.49
$120
.84
$260
.80
88-F
emal
e
Pre
ferr
ed$1
97.7
1 $3
46.0
3 $9
6.19
$2
80.1
5 $9
5.25
$2
05.0
6 99
- Fem
ale
S
tand
ard
$227
.07
$397
.63
$110
.32
$321
.88
$109
.23
$235
.53
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
Page
18
OH
8107
7NM
20
Hum
anaM
edica
re Su
pple
men
t Are
a 3M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
89 -M
ale
P
refe
rred
$226
.19
$396
.10
$109
.89
$320
.63
$108
.82
$234
.62
99-M
ale
S
tand
ard
$259
.82
$455
.21
$126
.08
$368
.42
$124
.84
$269
.51
89-F
emal
e
Pre
ferr
ed$2
03.9
1 $3
56.9
4 $9
9.17
$2
88.9
7 $9
8.20
$2
11.5
0 99
- Fem
ale
S
tand
ard
$234
.20
$410
.17
$113
.75
$332
.01
$112
.64
$242
.93
90 -M
ale
P
refe
rred
$233
.72
$409
.36
$113
.53
$331
.35
$112
.42
$242
.44
99-M
ale
S
tand
ard
$268
.49
$470
.45
$130
.25
$380
.76
$128
.97
$278
.51
90-F
emal
e
Pre
ferr
ed$2
10.3
1 $3
68.1
8 $1
02.2
6 $2
98.0
6 $1
01.2
5 $2
18.1
4 99
- Fem
ale
S
tand
ard
$241
.55
$423
.12
$117
.29
$342
.47
$116
.14
$250
.56
91 -M
ale
P
refe
rred
$241
.52
$423
.07
$117
.28
$342
.44
$116
.13
$250
.53
99-M
ale
S
tand
ard
$277
.45
$486
.22
$134
.57
$393
.50
$133
.25
$287
.81
91-F
emal
e
Pre
ferr
ed$2
16.9
0 $3
79.8
0 $1
05.4
3 $3
07.4
4 $1
04.4
0 $2
24.9
9 99
- Fem
ale
S
tand
ard
$249
.15
$436
.45
$120
.95
$353
.26
$119
.76
$258
.44
92 -M
ale
P
refe
rred
$249
.59
$437
.24
$121
.16
$353
.89
$119
.97
$258
.89
99-M
ale
S
tand
ard
$286
.72
$502
.52
$139
.03
$406
.67
$137
.66
$297
.43
92-F
emal
e
Pre
ferr
ed$2
23.7
2 $3
91.7
7 $1
08.7
1 $3
17.1
2 $1
07.6
4 $2
32.0
5 99
- Fem
ale
S
tand
ard
$256
.97
$450
.23
$124
.71
$364
.39
$123
.49
$266
.57
93 -M
ale
P
refe
rred
$257
.92
$451
.88
$125
.17
$365
.73
$123
.94
$267
.55
99-M
ale
S
tand
ard
$296
.31
$519
.37
$143
.65
$420
.29
$142
.23
$307
.38
93-F
emal
e
Pre
ferr
ed$2
30.7
5 $4
04.1
1 $1
12.1
0 $3
27.1
1 $1
10.9
9 $2
39.3
5 99
- Fem
ale
S
tand
ard
$265
.06
$464
.43
$128
.60
$375
.88
$127
.34
$274
.95
94 -M
ale
P
refe
rred
$266
.54
$467
.02
$129
.31
$377
.98
$128
.04
$276
.48
99-M
ale
S
tand
ard
$306
.21
$536
.78
$148
.41
$434
.37
$146
.96
$317
.65
94-F
emal
e
Pre
ferr
ed$2
37.9
9 $4
16.8
6 $1
15.5
8 $3
37.4
2 $1
14.4
5 $2
46.8
7 99
- Fem
ale
S
tand
ard
$273
.40
$479
.08
$132
.62
$387
.72
$131
.31
$283
.60
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.(C
ontin
ued
on n
ext p
age)
OH
8107
7NM
20
Page
19
Hum
anaM
edica
re Su
pple
men
t Are
a 3M
onth
ly Pr
emiu
ms
Effe
ctiv
e Da
te: 0
8-01
-202
1At
tain
ed
Age
&Ge
nder
Pr
emiu
m
Type
Pl
an A
Plan
F
High
De
duct
ible
Pl
an F
Pl
an G
Hi
gh
Dedu
ctib
le
Plan
G
Plan
N
95 -M
ale
P
refe
rred
$275
.44
$482
.67
$133
.60
$390
.62
$132
.29
$285
.72
99-M
ale
S
tand
ard
$316
.45
$554
.78
$153
.34
$448
.93
$151
.84
$328
.28
95-F
emal
e
Pre
ferr
ed$2
45.4
8 $4
30.0
0 $1
19.1
9 $3
48.0
4 $1
18.0
1 $2
54.6
3 99
- Fem
ale
S
tand
ard
$282
.00
$494
.21
$136
.76
$399
.95
$135
.41
$292
.52
96 -M
ale
P
refe
rred
$284
.64
$498
.85
$138
.03
$403
.71
$136
.67
$295
.27
99-M
ale
S
tand
ard
$327
.04
$573
.38
$158
.43
$463
.96
$156
.87
$339
.26
96-F
emal
e
Pre
ferr
ed$2
53.1
9 $4
43.5
6 $1
22.8
9 $3
59.0
1 $1
21.6
9 $2
62.6
4 99
- Fem
ale
S
tand
ard
$290
.88
$509
.80
$141
.03
$412
.56
$139
.64
$301
.73
97 -M
ale
P
refe
rred
$294
.14
$515
.57
$142
.61
$417
.23
$141
.20
$305
.13
99-M
ale
S
tand
ard
$337
.98
$592
.60
$163
.70
$479
.50
$162
.09
$350
.61
97-F
emal
e
Pre
ferr
ed$2
61.1
5 $4
57.5
7 $1
26.7
2 $3
70.3
3 $1
25.4
8 $2
70.8
9 99
- Fem
ale
S
tand
ard
$300
.02
$525
.90
$145
.43
$425
.57
$144
.01
$311
.23
98 -M
ale
P
refe
rred
$303
.98
$532
.85
$147
.34
$431
.21
$145
.89
$315
.34
99-M
ale
S
tand
ard
$349
.28
$612
.49
$169
.14
$495
.58
$167
.47
$362
.34
98-F
emal
e
Pre
ferr
ed$2
69.3
6 $4
72.0
0 $1
30.6
8 $3
82.0
0 $1
29.3
9 $2
79.4
2 99
- Fem
ale
S
tand
ard
$309
.46
$542
.50
$149
.98
$439
.00
$148
.51
$321
.03
99 +-
Mal
e
Pre
ferr
ed$3
14.1
5 $5
50.7
3 $1
52.2
3 $4
45.6
5 $1
50.7
3 $3
25.8
8 99
-Mal
e
Sta
ndar
d$3
60.9
7 $6
33.0
3 $1
74.7
7 $5
12.1
9 $1
73.0
4 $3
74.4
6 99
+-Fe
mal
e
Pre
ferr
ed$2
77.8
3 $4
86.9
0 $1
34.7
5 $3
94.0
4 $1
33.4
4 $2
88.2
1 99
- Fem
ale
S
tand
ard
$319
.21
$559
.62
$154
.67
$452
.85
$153
.15
$331
.14
Note
: If y
ou a
re g
oing
to h
ave
a bi
rthd
ay w
ithin
the
mon
th o
f you
r req
uest
ed c
over
age
effe
ctiv
e da
te, p
leas
e us
e th
e ag
e yo
u w
ill be
turn
ing
on th
at
birt
hday
to d
eter
min
e yo
ur p
lan
prem
ium
rate
.Sa
ve o
n yo
ur p
rem
ium
whe
n m
ore
than
one
mem
ber o
f you
r hou
seho
ld a
pplie
s fo
r or i
s a
polic
yhol
der o
f a H
uman
a M
edic
are
Supp
lem
ent p
lan.
If y
ou
qual
ify, m
ultip
ly a
bove
rate
s by
0.9
5w
hich
is e
quiv
alen
t to
a 5%
disc
ount
. In
addi
tion,
sav
e $2
per
mon
th b
y el
ectin
g to
mak
e pa
ymen
ts e
lect
roni
cally
.
Page
20
OH
8107
7NM
20
Prem
ium
Info
rmat
ion
We,
Hum
ana
Bene
fit P
lan
of Il
linoi
s, In
c., c
an o
nly
chan
ge t
he re
new
al p
rem
ium
for y
our p
olic
y if
we
also
cha
nge
the
rene
wal
pre
miu
m fo
r all
polic
ies
that
we
issu
e lik
e yo
urs
in th
is S
tate
. No
chan
ge in
pre
miu
m w
ill b
e m
ade
beca
use
of th
e nu
mbe
r of
cla
ims
you
file,
nor
bec
ause
of a
chan
ge in
you
r he
alth
or y
our t
ype
of w
ork.
Th
is is
an
atta
ined
age
rate
d po
licy,
whi
ch m
eans
tha
t you
r pre
miu
ms
will
incr
ease
bas
ed o
n ag
e. Y
our a
ttai
ned
age
prem
ium
incr
ease
will
go
into
ef
fect
on
the
first
mon
thly
rene
wal
dat
e w
hich
falls
on
or fo
llow
s th
e po
licy
annu
al a
nniv
ersa
ry d
ate.
The
pre
miu
m in
crea
se w
ill b
e ba
sed
on y
our a
ge
atta
ined
on
or b
efor
e th
e la
st d
ay o
f the
rene
wal
cal
enda
r mon
th. A
prem
ium
cha
nge
will
not
be
mad
e m
ore
than
onc
e in
a12
-mon
th p
erio
d.
Prem
ium
dis
coun
ts m
ay b
e ap
plie
d or
dis
cont
inue
d ba
sed
on e
ligib
ility
.
Stan
dard
/Pre
ferr
ed
Durin
g O
pen
Enro
llmen
t an
d Gu
aran
teed
Iss
ue p
erio
ds, t
he p
refe
rred
rate
app
lies.
If y
ou a
re n
ot a
pply
ing
durin
g op
en e
nrol
lmen
t or
qua
lify
for
guar
ante
ed is
sue,
ast
anda
rd r
ate
will
be
appl
ied
if yo
u ha
ve u
sed
toba
cco
prod
ucts
with
in th
e la
st 1
2 m
onth
s or
you
qua
lifie
d fo
r Med
icar
e co
vera
ge
prio
r to
age
65.
Hous
ehol
d Di
scou
nt
You
are
elig
ible
for a
prem
ium
dis
coun
t if
in y
our h
ouse
hold
you
resi
de w
ith a
t lea
st o
ne o
ther
Med
icar
e-el
igib
le p
erso
n an
d th
at p
erso
n ow
ns o
r is
issu
ed a
Med
icar
e Su
pple
men
t in
sura
nce
polic
y by
us.
H
ouse
hold
is d
efin
ed a
s a
cond
omin
ium
uni
t, a
sing
le fa
mily
hom
e, o
r an
apar
tmen
t un
it w
ithin
an
apar
tmen
t co
mpl
ex.
We
rese
rve
the
right
to m
ake
chan
ges
to th
e pr
emiu
m d
isco
unt
stru
ctur
e. I
f ach
ange
to
the
disc
ount
str
uctu
re o
ccur
s to
you
r pol
icy,
it w
ill a
ffec
t all
polic
ies
we
issu
e lik
e yo
urs.
Th
e ho
useh
old
prem
ium
dis
coun
t w
ill b
e re
mov
ed if
the
othe
r Med
icar
e Su
pple
men
t in
sura
nce
polic
yhol
der w
hose
pol
icy
stat
us e
ntitl
es y
ou to
the
disc
ount
no
long
er re
side
s w
ith y
ou, t
heir
polic
y is
vol
unta
rily
or in
volu
ntar
ily te
rmin
ated
or u
pon
thei
r dea
th. T
his
prem
ium
cha
nge
will
occ
ur o
n th
e bi
lling
cyc
le fo
llow
ing
the
date
we
lear
n yo
ur e
ligib
ility
has
end
ed.
Disc
losu
re
Use
this
out
line
to c
ompa
re b
enef
its a
nd p
rem
ium
s am
ong
polic
ies.
Read
you
r pol
icy
very
car
eful
ly
This
is o
nly
an o
utlin
e de
scrib
ing
your
pol
icy'
s m
ost
impo
rtan
t fe
atur
es. T
he p
olic
y is
you
r ins
uran
ce c
ontr
act.
You
mus
t re
ad th
e po
licy
itsel
f to
unde
rsta
nd a
ll of
the
right
s an
d du
ties
of b
oth
you
and
your
insu
ranc
e co
mpa
ny.
OH
8107
7NM
20
Page
21
Righ
t to
retu
rn p
olic
y If
you
find
that
you
are
not
sat
isfie
d w
ith y
our p
olic
y, y
ou m
ay re
turn
it to
: H
uman
a Be
nefit
Pla
n of
Illin
ois,
Inc.
At
tn: M
edic
are
Enro
llmen
ts
P.O
. Box
141
68
Lexi
ngto
n, K
Y 40
512-
4168
If
you
sen
d th
e po
licy
back
to u
s w
ithin
30
days
aft
er y
ou re
ceiv
e it,
we
will
trea
t the
pol
icy
as if
it h
ad n
ever
bee
n is
sued
and
retu
rn a
ll of
you
r pa
ymen
ts le
ss a
ny c
laim
s pa
id.
Polic
y re
plac
emen
t If
you
are
repl
acin
g an
othe
r hea
lth in
sura
nce
polic
y, d
o N
OT
canc
el it
unt
il yo
u ha
ve a
ctua
lly re
ceiv
ed y
our n
ew p
olic
y an
d ar
e su
re y
ou w
ant t
o ke
ep it
.
Notic
e
This
pol
icy
may
not
fully
cov
er a
ll of
you
r m
edic
al c
osts
. N
eith
er H
uman
a Be
nefit
Pla
n of
Illin
ois,
Inc.
nor
its
agen
ts a
re c
onne
cted
with
Med
icar
e.
This
Out
line
of C
over
age
does
not
giv
e al
l the
det
ails
of M
edic
are
cove
rage
. Con
tact
you
r loc
al S
ocia
l Sec
urity
Off
ice
or c
onsu
lt th
e "M
edic
are
&Yo
u"
hand
book
for m
ore
deta
ils.
Com
plet
e an
swer
s are
ver
y im
port
ant
Whe
n yo
u fil
l out
the
appl
icat
ion
for t
he n
ew p
olic
y, b
e su
re to
trut
hful
ly a
nd c
ompl
etel
y an
swer
all
ques
tions
abo
ut y
our m
edic
al a
nd h
ealth
his
tory
. Th
e co
mpa
ny m
ay c
ance
l you
r pol
icy
and
refu
se t
o pa
y an
y cl
aim
s if
you
leav
e ou
t or f
alsi
fy im
port
ant
med
ical
info
rmat
ion.
Re
view
the
appl
icat
ion
care
fully
bef
ore
you
sign
it. B
e ce
rtai
n th
at a
ll in
form
atio
n ha
s be
en p
rope
rly re
cord
ed.
Page
22
OH
8107
7NM
20
Plan
AM
edic
are
Part
A-H
ospi
tal S
ervi
ces
-Per
Ben
efit
Perio
d *
Abe
nefit
per
iod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hosp
ital a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
ha
ve n
ot re
ceiv
ed s
kille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
.
**NO
TICE
: Whe
n yo
ur M
edic
are
Part
Aho
spita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds
in th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y's
"Cor
e Be
nefit
s."
Durin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
from
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diff
eren
ce b
etw
een
its b
illed
cha
rges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hosp
italiz
atio
n*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursi
ng a
nd
mis
cella
neou
s se
rvic
es a
nd s
uppl
ies
Firs
t 60
days
61
st th
roug
h 90
th d
ay
91st
day
and
aft
er:
–W
hile
usi
ng 6
0 lif
etim
e re
serv
e da
ys
–O
nce
lifet
ime
rese
rve
days
are
use
d:
•Ad
ditio
nal 3
65 d
ays
•Be
yond
the
addi
tiona
l 365
day
s
All b
ut $
1,48
4 Al
l but
$37
1 a
day
All b
ut $
742
ada
y
$0
$0
$0
$371
ada
y
$742
ada
y
100%
of M
edic
are
elig
ible
exp
ense
s $0
$1,4
84 (P
art A
dedu
ctib
le)
$0
$0
$0**
Al
l cos
ts
Skill
ed N
ursi
ng F
acili
ty C
are*
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
ha
ving
bee
n in
aho
spita
l for
at l
east
thre
e da
ys
and
ente
red
aM
edic
are-
appr
oved
fac
ility
with
in 3
0 da
ys a
fter
leav
ing
the
hosp
ital
Firs
t 20
days
21
st th
roug
h 10
0th
day
101s
t day
and
aft
er
All a
ppro
ved
amou
nts
All b
ut $
185.
50 a
day
$0
$0
$0
$0
$0
Up
to $
185.
50 a
day
All c
osts
Bloo
d Fi
rst t
hree
pin
ts
Addi
tiona
l am
ount
s $0
10
0%
Thre
e pi
nts
$0
$0
$0
Hosp
ice
Care
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
a
doct
or's
cer
tific
atio
n of
term
inal
illn
ess.
Al
l but
ver
y lim
ited
copa
ymen
t/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coi
nsur
ance
$0
OH
8107
7NM
20
Page
23
Plan
AM
edic
are
(Par
t B) -
Med
ical
Ser
vice
s -P
er C
alen
dar Y
ear
*O
nce
you
have
bee
n bi
lled
$203
of M
edic
are-
appr
oved
am
ount
s fo
r cov
ered
ser
vice
s (w
hich
are
not
ed w
ith a
n as
teris
k), y
our P
art B
dedu
ctib
le
will
hav
e be
en m
et fo
r the
cal
enda
r yea
r.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Med
ical
Exp
ense
s In
or o
ut o
f the
hos
pita
l and
out
patie
nt h
ospi
tal
trea
tmen
t, su
ch a
s Ph
ysic
ian'
s se
rvic
es, i
npat
ient
an
d ou
tpat
ient
med
ical
and
sur
gica
l ser
vice
s an
d su
pplie
s, p
hysi
cal a
nd s
peec
h th
erap
y, d
iagn
ostic
te
sts,
dur
able
med
ical
equ
ipm
ent
Firs
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
Gene
rally
80%
$0
Gene
rally
20%
$203
(Par
t Bde
duct
ible
)
$0
Part
BEx
cess
Cha
rges
(abo
ve
Med
icar
e-ap
prov
ed a
mou
nts)
$0
$0
Al
l cos
ts
Bloo
d Fi
rst t
hree
pin
ts
Nex
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
$0
80%
All c
osts
$0
20%
$0
$203
(Par
t Bde
duct
ible
)
$0
Clin
ical
Lab
orat
ory
Serv
ices
–Te
sts
for
Diag
nost
ic s
ervi
ces
100%
$0
$0
Part
s A
and
B
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hom
e He
alth
Car
e
Med
icar
e Ap
prov
ed S
ervi
ces
•M
edic
ally
nec
essa
ry s
kille
d ca
re s
ervi
ces
and
med
ical
sup
plie
s •
Dura
ble
med
ical
equ
ipm
ent
Firs
t $20
3 of
M
edic
are-
appr
oved
am
ount
s*
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s
100%
$0
80%
$0
$0
20%
$0
$203
(Par
t Bde
duct
ible
)
$0
Page
24
OH
8107
7NM
20
Plan
FM
edic
are
Part
A-H
ospi
tal S
ervi
ces
-Per
Ben
efit
Perio
d *
Abe
nefit
per
iod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hosp
ital a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
ha
ve n
ot re
ceiv
ed s
kille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
.
**NO
TICE
: Whe
n yo
ur M
edic
are
Part
Aho
spita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds
in th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y's
"Cor
e Be
nefit
s."
Durin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
from
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diff
eren
ce b
etw
een
its b
illed
cha
rges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hosp
italiz
atio
n*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursi
ng a
nd
mis
cella
neou
s se
rvic
es a
nd s
uppl
ies
Firs
t 60
days
61
st th
roug
h 90
th d
ay
91st
day
and
aft
er:
–W
hile
usi
ng 6
0 lif
etim
e re
serv
e da
ys
–O
nce
lifet
ime
rese
rve
days
are
use
d:
•Ad
ditio
nal 3
65 d
ays
•Be
yond
the
addi
tiona
l 365
day
s
All b
ut $
1,48
4 Al
l but
$37
1 a
day
All b
ut $
742
ada
y
$0
$0
$1,4
84 (P
art A
dedu
ctib
le)
$371
ada
y
$742
ada
y
100%
of M
edic
are
elig
ible
exp
ense
s $0
$0
$0
$0
$0**
Al
l cos
ts
Skill
ed N
ursi
ng F
acili
ty C
are*
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
ha
ving
bee
n in
aho
spita
l for
at l
east
thre
e da
ys
and
ente
red
aM
edic
are-
appr
oved
fac
ility
with
in 3
0 da
ys a
fter
leav
ing
the
hosp
ital
Firs
t 20
days
21
st th
roug
h 10
0th
day
101s
t day
and
aft
er
All a
ppro
ved
amou
nts
All b
ut $
185.
50 a
day
$0
$0
Up
to $
185.
50 a
day
$0
$0
$0
All c
osts
Bloo
d Fi
rst t
hree
pin
ts
Addi
tiona
l am
ount
s $0
10
0%
Thre
e pi
nts
$0
$0
$0
Hosp
ice
Care
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
a
doct
or's
cer
tific
atio
n of
term
inal
illn
ess.
Al
l but
ver
y lim
ited
copa
ymen
t/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coi
nsur
ance
$0
OH
8107
7NM
20
Page
25
Plan
FM
edic
are
(Par
t B) -
Med
ical
Ser
vice
s -P
er C
alen
dar Y
ear
*O
nce
you
have
bee
n bi
lled
$203
of M
edic
are-
appr
oved
am
ount
s fo
r cov
ered
ser
vice
s (w
hich
are
not
ed w
ith a
n as
teris
k), y
our P
art B
dedu
ctib
le
will
hav
e be
en m
et fo
r the
cal
enda
r yea
r.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Med
ical
Exp
ense
s In
or o
ut o
f the
hos
pita
l and
out
patie
nt h
ospi
tal
trea
tmen
t, su
ch a
s Ph
ysic
ian'
s se
rvic
es, i
npat
ient
an
d ou
tpat
ient
med
ical
and
sur
gica
l ser
vice
s an
d su
pplie
s, p
hysi
cal a
nd s
peec
h th
erap
y, d
iagn
ostic
te
sts,
dur
able
med
ical
equ
ipm
ent
Firs
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
Gene
rally
80%
$203
(Par
t Bde
duct
ible
)
Gene
rally
20%
$0
$0
Part
BEx
cess
Cha
rges
(abo
ve
Med
icar
e-ap
prov
ed a
mou
nts)
$0
10
0%
$0
Bloo
d Fi
rst t
hree
pin
ts
Nex
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
$0
80%
All c
osts
$203
(Par
t Bde
duct
ible
)
20%
$0
$0
$0
Clin
ical
Lab
orat
ory
Serv
ices
–Te
sts
for
Diag
nost
ic s
ervi
ces
100%
$0
$0
Part
s A
and
B
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hom
e He
alth
Car
e
Med
icar
e Ap
prov
ed S
ervi
ces
•M
edic
ally
nec
essa
ry s
kille
d ca
re s
ervi
ces
and
med
ical
sup
plie
s •
Dura
ble
med
ical
equ
ipm
ent
Firs
t $20
3 of
M
edic
are-
appr
oved
am
ount
s*
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s
100%
$0
80%
$0
$203
(Par
t Bde
duct
ible
)
20%
$0
$0
$0
Page
26
OH
8107
7NM
20
Plan
FOt
her B
enef
its -
Not C
over
ed B
y M
edic
are
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Fore
ign
Trav
el –
NOT
COVE
RED
BY M
EDIC
ARE
Med
ical
ly n
eces
sary
em
erge
ncy
care
ser
vice
s be
ginn
ing
durin
g th
e fir
st 6
0 da
ys o
f eac
h tr
ip
outs
ide
of th
e U
SA
Firs
t $25
0 ea
ch c
alen
dar y
ear
Rem
aind
er o
f cha
rges
$0
$0
$0
80%
to a
lifet
ime
max
imum
ben
efit
of $
50,0
00
$250
20%
and
am
ount
s ov
er th
e $5
0,00
0 lif
etim
e m
axim
um
OH
8107
7NM
20
Page
27
***N
OTIC
E: W
hen
your
Med
icar
e Pa
rt A
hosp
ital b
enef
its a
re e
xhau
sted
, the
insu
rer s
tand
s in
the
plac
e of
Med
icar
e an
d w
ill p
ay w
hate
ver
amou
nt M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y's
"Cor
e Be
nefit
s."
Durin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
from
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diff
eren
ce b
etw
een
its b
illed
cha
rges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
High
Ded
uctib
le P
lan
FM
edic
are
Part
A-H
ospi
tal S
ervi
ces
-Per
Ben
efit
Perio
d *
Abe
nefit
per
iod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hosp
ital a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
ha
ve n
ot re
ceiv
ed s
kille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
. **
This
hig
h de
duct
ible
pla
n pa
ys th
e sa
me
bene
fits
as P
lan
Faf
ter y
ou h
ave
paid
aca
lend
ar y
ear $
2,37
0 de
duct
ible
. Ben
efits
from
the
high
de
duct
ible
Pla
n F
will
not
beg
in u
ntil
out-
of-p
ocke
t ex
pens
es a
re $
2,37
0. O
ut-o
f-po
cket
exp
ense
s fo
r thi
s de
duct
ible
are
exp
ense
s th
at w
ould
or
dina
rily
be p
aid
by th
e po
licy.
Thi
s in
clud
es t
he M
edic
are
dedu
ctib
les
for P
art A
and
Part
B, b
ut d
oes
not i
nclu
de th
e pl
an's
sep
arat
e fo
reig
n tr
avel
em
erge
ncy
dedu
ctib
le.
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) Ho
spita
lizat
ion*
Se
mip
rivat
e ro
om a
nd b
oard
, gen
eral
nur
sing
and
m
isce
llane
ous
serv
ices
and
sup
plie
s Fi
rst 6
0 da
ys
61st
thro
ugh
90th
day
91
st d
ay a
nd a
fter
: –
Whi
le u
sing
60
lifet
ime
rese
rve
days
–
Onc
e lif
etim
e re
serv
e da
ys a
re u
sed:
•
Addi
tiona
l 365
day
s •
Beyo
nd th
e ad
ditio
nal 3
65 d
ays
All b
ut $
1,48
4 Al
l but
$37
1 a
day
All b
ut $
742
ada
y
$0
$0
$1,4
84 (P
art A
dedu
ctib
le)
$371
ada
y
$742
ada
y
100%
of M
edic
are
elig
ible
exp
ense
s $0
$0
$0
$0
$0**
* Al
l cos
ts
Skill
ed N
ursi
ng F
acili
ty C
are*
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
ha
ving
bee
n in
aho
spita
l for
at l
east
thre
e da
ys a
nd
ente
red
aM
edic
are-
appr
oved
fac
ility
with
in 3
0 da
ys
afte
r lea
ving
the
hosp
ital
Firs
t 20
days
21
st th
roug
h 10
0th
day
101s
t day
and
aft
er
All a
ppro
ved
amou
nts
All b
ut $
185.
50 a
day
$0
$0
Up
to $
185.
50 a
day
$0
$0
$0
All c
osts
Bloo
d Fi
rst t
hree
pin
ts
Addi
tiona
l am
ount
s $0
10
0%
Thre
e pi
nts
$0
$0
$0
Hosp
ice
Care
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
a
doct
or's
cer
tific
atio
n of
term
inal
illn
ess.
Al
l but
ver
y lim
ited
copa
ymen
t/ c
oins
uran
ce
for o
utpa
tient
dru
gs a
nd
inpa
tient
resp
ite c
are
Med
icar
e co
paym
ent/
coi
nsur
ance
$0
Page
28
OH
8107
7NM
20
High
Ded
uctib
le P
lan
FM
edic
are
Part
B-M
edic
al S
ervi
ces
-Per
Cal
enda
r Yea
r *
Onc
e yo
u ha
ve b
een
bille
d $2
03 o
f Med
icar
e-ap
prov
ed a
mou
nts
for c
over
ed s
ervi
ces
(whi
ch a
re n
oted
with
an
aste
risk)
, you
r Par
t Bde
duct
ible
w
ill h
ave
been
met
for t
he c
alen
dar y
ear.
**Th
is h
igh
dedu
ctib
le p
lan
pays
the
sam
e be
nefit
s as
Pla
n F
afte
r you
hav
e pa
id a
cale
ndar
yea
r $2,
370
dedu
ctib
le. B
enef
its fr
om th
e hi
gh
dedu
ctib
le P
lan
Fw
ill n
ot b
egin
unt
il ou
t-of
-poc
ket
expe
nses
are
$2,
370.
Out
-of-
pock
et e
xpen
ses
for t
his
dedu
ctib
le a
re e
xpen
ses
that
wou
ld
ordi
naril
y be
pai
d by
the
polic
y. T
his
incl
udes
the
Med
icar
e de
duct
ible
s fo
r Par
t Aan
d Pa
rt B
, but
doe
s no
t inc
lude
the
plan
's s
epar
ate
fore
ign
trav
el e
mer
genc
y de
duct
ible
.
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) M
edic
al E
xpen
ses
In o
r out
of t
he h
ospi
tal a
nd o
utpa
tient
hos
pita
l tre
atm
ent,
such
as
Phy
sici
an's
ser
vice
s, in
patie
nt a
nd o
utpa
tient
med
ical
and
su
rgic
al s
ervi
ces
and
supp
lies,
phy
sica
l and
spe
ech
ther
apy,
di
agno
stic
tes
ts, d
urab
le m
edic
al e
quip
men
t
Firs
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
Gene
rally
80%
$203
(Par
t Bde
duct
ible
)
Gene
rally
20%
$0
$0
Part
BEx
cess
Cha
rges
(abo
ve M
edic
are-
appr
oved
am
ount
s)
$0
100%
$0
Bloo
d Fi
rst t
hree
pin
ts
Nex
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
$0
80%
All c
osts
$203
(Par
t Bde
duct
ible
)
20%
$0
$0
$0
Clin
ical
Lab
orat
ory
Serv
ices
–Te
sts
for D
iagn
ostic
ser
vice
s N
/A
N/A
N
/A
Part
s A
and
B
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) Ho
me
Heal
th C
are
M
edic
are
Appr
oved
Ser
vice
s •
Med
ical
ly n
eces
sary
ski
lled
care
ser
vice
s an
d m
edic
al s
uppl
ies
•Du
rabl
e m
edic
al e
quip
men
t Fi
rst $
203
of M
edic
are-
appr
oved
am
ount
s*
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s
100%
$0
80%
$0
$203
(Par
t Bde
duct
ible
)
20%
$0
$0
$0
OH
8107
7NM
20
Page
29
High
Ded
uctib
le P
lan
FOt
her B
enef
its -
Not C
over
ed B
y M
edic
are
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) Fo
reig
n Tr
avel
–NO
T CO
VERE
D BY
MED
ICAR
E M
edic
ally
nec
essa
ry e
mer
genc
y ca
re s
ervi
ces
begi
nnin
g du
ring
the
first
60
days
of e
ach
trip
ou
tsid
e of
the
USA
Firs
t $25
0 ea
ch c
alen
dar y
ear
Rem
aind
er o
f cha
rges
$0
$0
$0
80%
to a
lifet
ime
max
imum
ben
efit
of $
50,0
00
$250
20%
and
am
ount
s ov
er th
e $5
0,00
0 lif
etim
e m
axim
um
Page
30
OH
8107
7NM
20
Plan
GM
edic
are
Part
A-H
ospi
tal S
ervi
ces
-Per
Ben
efit
Perio
d *
Abe
nefit
per
iod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hosp
ital a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
ha
ve n
ot re
ceiv
ed s
kille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
.
**NO
TICE
: Whe
n yo
ur M
edic
are
Part
Aho
spita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds
in th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y's
"Cor
e Be
nefit
s."
Durin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
from
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diff
eren
ce b
etw
een
its b
illed
cha
rges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hosp
italiz
atio
n*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursi
ng a
nd
mis
cella
neou
s se
rvic
es a
nd s
uppl
ies
Firs
t 60
days
61
st th
roug
h 90
th d
ay
91st
day
and
aft
er:
–W
hile
usi
ng 6
0 lif
etim
e re
serv
e da
ys
–O
nce
lifet
ime
rese
rve
days
are
use
d:
•Ad
ditio
nal 3
65 d
ays
•Be
yond
the
addi
tiona
l 365
day
s
All b
ut $
1,48
4 Al
l but
$37
1 a
day
All b
ut $
742
ada
y
$0
$0
$1,4
84 (P
art A
dedu
ctib
le)
$371
ada
y
$742
ada
y
100%
of M
edic
are
elig
ible
exp
ense
s $0
$0
$0
$0
$0**
Al
l cos
ts
Skill
ed N
ursi
ng F
acili
ty C
are*
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
ha
ving
bee
n in
aho
spita
l for
at l
east
thre
e da
ys
and
ente
red
aM
edic
are-
appr
oved
fac
ility
with
in 3
0 da
ys a
fter
leav
ing
the
hosp
ital
Firs
t 20
days
21
st th
roug
h 10
0th
day
101s
t day
and
aft
er
All a
ppro
ved
amou
nts
All b
ut $
185.
50 a
day
$0
$0
Up
to $
185.
50 a
day
$0
$0
$0
All c
osts
Bloo
d Fi
rst t
hree
pin
ts
Addi
tiona
l am
ount
s $0
10
0%
Thre
e pi
nts
$0
$0
$0
Hosp
ice
Care
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
a
doct
or's
cer
tific
atio
n of
term
inal
illn
ess.
Al
l but
ver
y lim
ited
copa
ymen
t/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coi
nsur
ance
$0
OH
8107
7NM
20
Page
31
Plan
GM
edic
are
(Par
t B) -
Med
ical
Ser
vice
s -P
er C
alen
dar Y
ear
*O
nce
you
have
bee
n bi
lled
$203
of M
edic
are-
appr
oved
am
ount
s fo
r cov
ered
ser
vice
s (w
hich
are
not
ed w
ith a
n as
teris
k), y
our P
art B
dedu
ctib
le
will
hav
e be
en m
et fo
r the
cal
enda
r yea
r.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Med
ical
Exp
ense
s In
or o
ut o
f the
hos
pita
l and
out
patie
nt h
ospi
tal
trea
tmen
t, su
ch a
s Ph
ysic
ian'
s se
rvic
es, i
npat
ient
an
d ou
tpat
ient
med
ical
and
sur
gica
l ser
vice
s an
d su
pplie
s, p
hysi
cal a
nd s
peec
h th
erap
y, d
iagn
ostic
te
sts,
dur
able
med
ical
equ
ipm
ent
Firs
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
Gene
rally
80%
$0
Gene
rally
20%
$203
(Par
t Bde
duct
ible
)
$0
Part
BEx
cess
Cha
rges
(abo
ve
Med
icar
e-ap
prov
ed a
mou
nts)
$0
10
0%
$0
Bloo
d Fi
rst t
hree
pin
ts
Nex
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
$0
80%
All c
osts
$0
20%
$0
$203
(Par
t Bde
duct
ible
)
$0
Clin
ical
Lab
orat
ory
Serv
ices
–Te
sts
for
Diag
nost
ic s
ervi
ces
100%
$0
$0
Part
s A
and
B
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hom
e He
alth
Car
e
Med
icar
e Ap
prov
ed S
ervi
ces
•M
edic
ally
nec
essa
ry s
kille
d ca
re s
ervi
ces
and
med
ical
sup
plie
s •
Dura
ble
med
ical
equ
ipm
ent
Firs
t $20
3 of
M
edic
are-
appr
oved
am
ount
s*
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s
100%
$0
80%
$0
$0
20%
$0
$203
(Par
t Bde
duct
ible
)
$0
Page
32
OH
8107
7NM
20
Plan
GOt
her B
enef
its -
Not C
over
ed B
y M
edic
are
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Fore
ign
Trav
el –
NOT
COVE
RED
BY M
EDIC
ARE
Med
ical
ly n
eces
sary
em
erge
ncy
care
ser
vice
s be
ginn
ing
durin
g th
e fir
st 6
0 da
ys o
f eac
h tr
ip
outs
ide
of th
e U
SA
Firs
t $25
0 ea
ch c
alen
dar y
ear
Rem
aind
er o
f cha
rges
$0
$0
$0
80%
to a
lifet
ime
max
imum
ben
efit
of $
50,0
00
$250
20%
and
am
ount
s ov
er th
e $5
0,00
0 lif
etim
e m
axim
um
OH
8107
7NM
20
Page
33
***N
OTIC
E: W
hen
your
Med
icar
e Pa
rt A
hosp
ital b
enef
its a
re e
xhau
sted
, the
insu
rer s
tand
s in
the
plac
e of
Med
icar
e an
d w
ill p
ay w
hate
ver
amou
nt M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y's
"Cor
e Be
nefit
s."
Durin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
from
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diff
eren
ce b
etw
een
its b
illed
cha
rges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
High
Ded
uctib
le P
lan
GM
edic
are
Part
A-H
ospi
tal S
ervi
ces
-Per
Ben
efit
Perio
d *
Abe
nefit
per
iod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hosp
ital a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
ha
ve n
ot re
ceiv
ed s
kille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
. **
This
hig
h de
duct
ible
pla
n pa
ys th
e sa
me
bene
fits
as P
lan
Gaf
ter y
ou h
ave
paid
aca
lend
ar y
ear $
2,37
0 de
duct
ible
. Ben
efits
from
the
high
de
duct
ible
pla
n G
will
not
beg
in u
ntil
out-
of-p
ocke
t ex
pens
es a
re $
2,37
0. O
ut-o
f-po
cket
exp
ense
s fo
r thi
s de
duct
ible
incl
ude
expe
nses
for t
he
Med
icar
e Pa
rt B
dedu
ctib
le, a
nd e
xpen
ses
that
wou
ld o
rdin
arily
be
paid
by
the
polic
y. T
his
does
not
incl
ude
the
plan
's s
epar
ate
fore
ign
trav
el
emer
genc
y de
duct
ible
.
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) Ho
spita
lizat
ion*
Se
mip
rivat
e ro
om a
nd b
oard
, gen
eral
nur
sing
and
m
isce
llane
ous
serv
ices
and
sup
plie
s Fi
rst 6
0 da
ys
61st
thro
ugh
90th
day
91
st d
ay a
nd a
fter
: –
Whi
le u
sing
60
lifet
ime
rese
rve
days
–
Onc
e lif
etim
e re
serv
e da
ys a
re u
sed:
•
Addi
tiona
l 365
day
s •
Beyo
nd th
e ad
ditio
nal 3
65 d
ays
All b
ut $
1,48
4 Al
l but
$37
1 a
day
All b
ut $
742
ada
y
$0
$0
$1,4
84 (P
art A
dedu
ctib
le)
$371
ada
y
$742
ada
y
100%
of M
edic
are
elig
ible
exp
ense
s $0
$0
$0
$0
$0**
* Al
l cos
ts
Skill
ed N
ursi
ng F
acili
ty C
are*
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
ha
ving
bee
n in
aho
spita
l for
at l
east
thre
e da
ys a
nd
ente
red
aM
edic
are-
appr
oved
fac
ility
with
in 3
0 da
ys
afte
r lea
ving
the
hosp
ital
Firs
t 20
days
21
st th
roug
h 10
0th
day
101s
t day
and
aft
er
All a
ppro
ved
amou
nts
All b
ut $
185.
50 a
day
$0
$0
Up
to $
185.
50 a
day
$0
$0
$0
All c
osts
Bloo
d Fi
rst t
hree
pin
ts
Addi
tiona
l am
ount
s $0
10
0%
Thre
e pi
nts
$0
$0
$0
Hosp
ice
Care
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
a
doct
or's
cer
tific
atio
n of
term
inal
illn
ess.
Al
l but
ver
y lim
ited
copa
ymen
t/ c
oins
uran
ce
for o
utpa
tient
dru
gs a
nd
inpa
tient
resp
ite c
are
Med
icar
e co
paym
ent/
coi
nsur
ance
$0
Page
34
OH
8107
7NM
20
High
Ded
uctib
le P
lan
GM
edic
are
Part
B-M
edic
al S
ervi
ces
-Per
Cal
enda
r Yea
r *
Onc
e yo
u ha
ve b
een
bille
d $2
03 o
f Med
icar
e-ap
prov
ed a
mou
nts
for c
over
ed s
ervi
ces
(whi
ch a
re n
oted
with
an
aste
risk)
, you
r Par
t Bde
duct
ible
w
ill h
ave
been
met
for t
he c
alen
dar y
ear.
**Th
is h
igh
dedu
ctib
le p
lan
pays
the
sam
e be
nefit
s as
Pla
n G
afte
r you
hav
e pa
id a
cale
ndar
yea
r $2,
370
dedu
ctib
le. B
enef
its fr
om th
e hi
gh
dedu
ctib
le p
lan
Gw
ill n
ot b
egin
unt
il ou
t-of
-poc
ket
expe
nses
are
$2,
370.
Out
-of-
pock
et e
xpen
ses
for t
his
dedu
ctib
le in
clud
e ex
pens
es fo
r the
M
edic
are
Part
Bde
duct
ible
, and
exp
ense
s th
at w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
Thi
s do
es n
ot in
clud
e th
e pl
an's
sep
arat
e fo
reig
n tr
avel
em
erge
ncy
dedu
ctib
le.
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) M
edic
al E
xpen
ses
In o
r out
of t
he h
ospi
tal a
nd o
utpa
tient
hos
pita
l tre
atm
ent,
such
as
Phy
sici
an's
ser
vice
s, in
patie
nt a
nd o
utpa
tient
med
ical
and
su
rgic
al s
ervi
ces
and
supp
lies,
phy
sica
l and
spe
ech
ther
apy,
di
agno
stic
tes
ts, d
urab
le m
edic
al e
quip
men
t
Firs
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
Gene
rally
80%
$0
Gene
rally
20%
$203
(Unl
ess
Part
B
dedu
ctib
le h
as b
een
met
)
$0
Part
BEx
cess
Cha
rges
(abo
ve M
edic
are-
appr
oved
am
ount
s)
$0
100%
$0
Bloo
d Fi
rst t
hree
pin
ts
Nex
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
$0
80%
All c
osts
$0
20%
$0
$203
(Unl
ess
Part
B
dedu
ctib
le h
as b
een
met
)
$0
Clin
ical
Lab
orat
ory
Serv
ices
–Te
sts
for D
iagn
ostic
ser
vice
s 10
0%
$0
$0
Part
s A
and
B
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) Ho
me
Heal
th C
are
M
edic
are
Appr
oved
Ser
vice
s •
Med
ical
ly n
eces
sary
ski
lled
care
ser
vice
s an
d m
edic
al s
uppl
ies
•Du
rabl
e m
edic
al e
quip
men
t Fi
rst $
203
of M
edic
are-
appr
oved
am
ount
s*
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s
100%
$0
80%
$0
$0
20%
$0
$203
(Unl
ess
Part
B
dedu
ctib
le h
as b
een
met
) $0
OH
8107
7NM
20
Page
35
High
Ded
uctib
le P
lan
GOt
her B
enef
its -
Not C
over
ed B
y M
edic
are
Serv
ices
M
edic
are
Pays
Pl
an P
ays (
Afte
r You
pay
$2
,370
Ded
uctib
le**
) Yo
u Pa
y (I
n ad
ditio
n to
$2
,370
Ded
uctib
le**
) Fo
reig
n Tr
avel
–NO
T CO
VERE
D BY
MED
ICAR
E M
edic
ally
nec
essa
ry e
mer
genc
y ca
re s
ervi
ces
begi
nnin
g du
ring
the
first
60
days
of e
ach
trip
ou
tsid
e of
the
USA
Firs
t $25
0 ea
ch c
alen
dar y
ear
Rem
aind
er o
f cha
rges
$0
$0
$0
80%
to a
lifet
ime
max
imum
ben
efit
of $
50,0
00
$250
20%
and
am
ount
s ov
er th
e $5
0,00
0 lif
etim
e m
axim
um
Page
36
OH
8107
7NM
20
Plan
NM
edic
are
Part
A-H
ospi
tal S
ervi
ces
-Per
Ben
efit
Perio
d *
Abe
nefit
per
iod
begi
ns o
n th
e fir
st d
ay y
ou re
ceiv
e se
rvic
e as
an
inpa
tient
in a
hosp
ital a
nd e
nds
afte
r you
hav
e be
en o
ut o
f the
hos
pita
l and
ha
ve n
ot re
ceiv
ed s
kille
d ca
re in
any
oth
er fa
cilit
y fo
r 60
days
in a
row
.
**NO
TICE
: Whe
n yo
ur M
edic
are
Part
Aho
spita
l ben
efits
are
exh
aust
ed, t
he in
sure
r sta
nds
in th
e pl
ace
of M
edic
are
and
will
pay
wha
teve
r am
ount
M
edic
are
wou
ld h
ave
paid
for u
p to
an
addi
tiona
l 365
day
s as
pro
vide
d in
the
polic
y's
"Cor
e Be
nefit
s."
Durin
g th
is ti
me
the
hosp
ital i
s pr
ohib
ited
from
bill
ing
you
for t
he b
alan
ce b
ased
on
any
diff
eren
ce b
etw
een
its b
illed
cha
rges
and
the
amou
nt M
edic
are
wou
ld h
ave
paid
.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hosp
italiz
atio
n*
Sem
ipriv
ate
room
and
boa
rd, g
ener
al n
ursi
ng a
nd
mis
cella
neou
s se
rvic
es a
nd s
uppl
ies
Firs
t 60
days
61
st th
roug
h 90
th d
ay
91st
day
and
aft
er:
–W
hile
usi
ng 6
0 lif
etim
e re
serv
e da
ys
–O
nce
lifet
ime
rese
rve
days
are
use
d:
•Ad
ditio
nal 3
65 d
ays
•Be
yond
the
addi
tiona
l 365
day
s
All b
ut $
1,48
4 Al
l but
$37
1 a
day
All b
ut $
742
ada
y
$0
$0
$1,4
84 (P
art A
dedu
ctib
le)
$371
ada
y
$742
ada
y
100%
of M
edic
are
elig
ible
exp
ense
s $0
$0
$0
$0
$0**
Al
l cos
ts
Skill
ed N
ursi
ng F
acili
ty C
are*
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
ha
ving
bee
n in
aho
spita
l for
at l
east
thre
e da
ys
and
ente
red
aM
edic
are-
appr
oved
fac
ility
with
in 3
0 da
ys a
fter
leav
ing
the
hosp
ital
Firs
t 20
days
21
st th
roug
h 10
0th
day
101s
t day
and
aft
er
All a
ppro
ved
amou
nts
All b
ut $
185.
50 a
day
$0
$0
Up
to $
185.
50 a
day
$0
$0
$0
All c
osts
Bloo
d Fi
rst t
hree
pin
ts
Addi
tiona
l am
ount
s $0
10
0%
Thre
e pi
nts
$0
$0
$0
Hosp
ice
Care
Yo
u m
ust
mee
t M
edic
are'
s re
quire
men
ts, i
nclu
ding
a
doct
or's
cer
tific
atio
n of
term
inal
illn
ess.
Al
l but
ver
y lim
ited
copa
ymen
t/
coin
sura
nce
for
outp
atie
nt d
rugs
and
in
patie
nt re
spite
car
e
Med
icar
e co
paym
ent/
coi
nsur
ance
$0
OH
8107
7NM
20
Page
37
Plan
NM
edic
are
(Par
t B) -
Med
ical
Ser
vice
s -P
er C
alen
dar Y
ear
*O
nce
you
have
bee
n bi
lled
$203
of M
edic
are-
appr
oved
am
ount
s fo
r cov
ered
ser
vice
s (w
hich
are
not
ed w
ith a
n as
teris
k), y
our P
art B
dedu
ctib
le
will
hav
e be
en m
et fo
r the
cal
enda
r yea
r.
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Med
ical
Exp
ense
s In
or o
ut o
f the
hos
pita
l and
out
patie
nt h
ospi
tal
trea
tmen
t, su
ch a
s Ph
ysic
ian'
s se
rvic
es, i
npat
ient
an
d ou
tpat
ient
med
ical
and
sur
gica
l ser
vice
s an
d su
pplie
s, p
hysi
cal a
nd s
peec
h th
erap
y, d
iagn
ostic
te
sts,
dur
able
med
ical
equ
ipm
ent
Firs
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
Gene
rally
80%
$0
Bala
nce,
oth
er th
an u
p to
$20
per
of
fice
visi
t and
up
to $
50 p
er
emer
genc
y ro
om v
isit.
The
cop
aym
ent
of u
p to
$50
is w
aive
d if
the
insu
red
is
adm
itted
to
any
hosp
ital a
nd th
e em
erge
ncy
visi
t is
cove
red
as a
M
edic
are
Part
Aex
pens
e.
$203
(Par
t Bde
duct
ible
)
Up
to $
20 p
er o
ffic
e vi
sit a
nd u
p to
$50
per
em
erge
ncy
room
vis
it.
The
copa
ymen
t of
up
to $
50 is
w
aive
d if
the
insu
red
is a
dmitt
ed
to a
ny h
ospi
tal a
nd th
e em
erge
ncy
visi
t is
cove
red
as a
M
edic
are
Part
Aex
pens
e.
Part
BEx
cess
Cha
rges
(abo
ve
Med
icar
e-ap
prov
ed a
mou
nts)
$0
$0
Al
l cos
ts (s
ubje
ct t
o an
y ap
plic
able
Sta
te o
r Fed
eral
re
stric
tions
on
such
cha
rges
)
Bloo
d Fi
rst t
hree
pin
ts
Nex
t $20
3 of
Med
icar
e-ap
prov
ed a
mou
nts*
Rem
aind
er o
f Med
icar
e-ap
prov
ed a
mou
nts
$0
$0
80%
All c
osts
$0
20%
$0
$203
(Par
t Bde
duct
ible
)
$0
Clin
ical
Lab
orat
ory
Serv
ices
–Te
sts
for
Diag
nost
ic s
ervi
ces
100%
$0
$0
Part
s A
and
B
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Hom
e He
alth
Car
e
Med
icar
e Ap
prov
ed S
ervi
ces
•M
edic
ally
nec
essa
ry s
kille
d ca
re s
ervi
ces
and
med
ical
sup
plie
s •
Dura
ble
med
ical
equ
ipm
ent
Firs
t $20
3 of
M
edic
are-
appr
oved
am
ount
s*
•Re
mai
nder
of M
edic
are-
appr
oved
am
ount
s
100%
$0
80%
$0
$0
20%
$0
$203
(Par
t Bde
duct
ible
)
$0
Page
38
OH
8107
7NM
20
Plan
N
Serv
ices
M
edic
are
Pays
Pl
an P
ays
You
Pay
Fore
ign
Trav
el –
NOT
COVE
RED
BY M
EDIC
ARE
Med
ical
ly n
eces
sary
em
erge
ncy
care
ser
vice
s be
ginn
ing
durin
g th
e fir
st 6
0 da
ys o
f eac
h tr
ip
outs
ide
of th
e U
SA
Firs
t $25
0 ea
ch c
alen
dar y
ear
Rem
aind
er o
f cha
rges
$0
$0
$0
80%
to a
lifet
ime
max
imum
ben
efit
of $
50,0
00
$250
20%
and
am
ount
s ov
er th
e $5
0,00
0 lif
etim
e m
axim
um
Othe
r Ben
efits
-No
t Cov
ered
By
Med
icar
e
OH
8107
7NM
20
Page
39
Note
s
Page
40
OH
8107
7NM
20
Note
s
OH
8107
7NM
20
Page
41
Note
s
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(Farsi) فارسیبرای دریافت تسهیلات زبانی بصورت رایگان با شماره فوق تماس بگیرید.
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(Arabic) العر بيةالرجاء الاتصال بالرقم المبين أعلاه للحصول على خدمات مجانية للمساعدة بلغتك
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Bla
nk
insi
de
bac
k co
ver.
Insu
red
by H
uman
a Be
nefit
Pla
n of
Illin
ois,
Inc.
OH8
1077
NM
20
821