OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, F AND G

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UNITED OF OMAHA LIFE INSURANCE COMPANY

A Mutual of Omaha Company

OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, F AND G

These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan "A." Some plans may not be available in your state. See Outlines of Coverage sections for details about ALL plans.

Basic Benefits for Plans A through J:

Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end

Medical Expenses: Part B coinsurance (generally 20% of Medicare approved expenses) or copayments for hospital outpatient services Blood: First 3 pints of blood each year

A B C D E F F* G H I J J*

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits

Basic Benefits Skilled

Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance

Skilled Nursing Facility Coinsurance Part A

Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible Part B

Deductible

Part B Deductible

Part B Deductible Part B Excess

100%

Part B Excess 80%

Part B Excess 100%

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency

Foreign Travel Emergency At-home

Recovery

At-home Recovery

At-home Recovery

At-home Recovery Preventive

Care NOT Covered by Medicare

Preventive Care NOT Covered by Medicare

*Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year $2,000 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses exceed $2,000.

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 plans' separate foreign travel emergency deductible.

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Basic Benefits: Plans K and L include similar services as Plans A through J, but cost-sharing for the basic benefits is at different levels.

J K** L**

Basic Benefits 100% of Part A Hospitalization coinsurance plus coverage for 365 days after Medicare benefits end 50% Hospice cost-sharing

50% of Medicare eligible expenses for the first three pints of Blood

50% Part B coinsurance, except 100% coinsurance for Part B Preventive Services

100% of Part A Hospitalization coinsurance plus coverage for 365 days after Medicare benefits end 75% Hospice cost-sharing

75% of Medicare eligible expenses for the first three pints of Blood

75% Part B coinsurance, except 100% coinsurance for Part B Preventive Services

50% Skilled Nursing Facility coinsurance

75% Skilled Nursing Facility coinsurance

Part A Deductible 50% Part A Deductible 75% Part A Deductible

Part B Deductible Part B Excess (100%) Foreign Travel Emergency At-Home Recovery

Preventive Care NOT Covered by Medicare

$4,620 Out-of-Pocket Annual Limit *** $2,310 Out-of-Pocket Annual Limit ***

**Plans K and L provide for different cost-sharing for items and services than Plans A through J. Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance and

deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges.

***The out-of-pocket annual limit will increase each year for inflation.

See Outlines of Coverage for details and exceptions.

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NON-TOBACCO

Plan A UM1

Plan F UM4

Plan G UM5

FEMALE MALE

Attained Age

Plan A UM1

Plan F UM4

Plan G UM5

UNITED OF OMAHA LIFE INSURANCE COMPANY

MONTHLY RATES*

ZIP CODES: 754-759, 762-769, 778-781, 783, 785-792, 795-799, 885

$163.51 Through 64 $181.70

$71.21 $103.20 $87.72 65 $74.95 $108.63 $92.34

$71.21 $103.20 $87.72 66 $74.95 $108.63 $92.34

$73.98 $107.22 $91.14 67 $78.71 $114.07 $96.95

$76.89 $111.43 $94.72 68 $82.68 $119.82 $101.85

$79.89 $115.78 $98.42 69 $86.84 $125.85 $106.97

$82.86 $120.07 $102.06 70 $91.04 $131.94 $112.16

$85.76 $124.30 $105.65 71 $95.30 $138.11 $117.40

$88.74 $128.60 $109.32 72 $99.70 $144.50 $122.82

$91.71 $132.91 $112.97 73 $104.22 $151.04 $128.38

$94.67 $137.21 $116.63 74 $108.83 $157.71 $134.06

$97.46 $141.24 $120.06 75 $113.32 $164.23 $139.60

$99.82 $144.67 $122.97 76 $117.43 $170.19 $144.67

$101.56 $147.18 $125.10 77 $119.48 $173.15 $147.18

$103.28 $149.68 $127.23 78 $121.51 $176.10 $149.68

$105.17 $152.41 $129.55 79 $123.72 $179.31 $152.41

$106.97 $155.03 $131.78 80 $125.85 $182.39 $155.03

$109.33 $158.45 $134.68 81 $127.13 $184.24 $156.60

$111.61 $161.75 $137.49 82 $128.29 $185.92 $158.03

$113.80 $164.93 $140.19 83 $129.32 $187.42 $159.31

$115.92 $168.02 $142.81 84 $130.26 $188.78 $160.46

$117.96 $170.96 $145.31 85 $131.07 $189.96 $161.46

$119.89 $173.76 $147.71 86 $131.76 $190.96 $162.32

$121.74 $176.44 $149.97 87 $132.33 $191.78 $163.01

$123.48 $178.96 $152.11 88 $132.77 $192.42 $163.56

$125.10 $181.31 $154.11 89 $133.09 $192.88 $163.95

$126.59 $183.46 $155.93 90 and Over $133.24 $193.10 $164.14

To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, and 3, respectively.

* See PREMIUM INFORMATION regarding Household Premium Discount rating.

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TOBACCO

Plan A UM1

Plan F UM4

Plan G UM5

FEMALE MALE

Plan A UM1

Plan F UM4

Plan G UM5 ZIP CODES: 754-759, 762-769, 778-781, 783, 785-792, 795-799, 885

$187.95 Through 64 $208.85

$81.85 $118.62 $100.83 65 $86.15 $124.87 $106.14

$81.85 $118.62 $100.83 66 $86.15 $124.87 $106.14

$85.03 $123.25 $104.76 67 $90.47 $131.11 $111.44

$88.38 $128.08 $108.87 68 $95.03 $137.73 $117.06

$91.83 $133.08 $113.12 69 $99.82 $144.66 $122.96

$95.24 $138.02 $117.32 70 $104.64 $151.66 $128.92

$98.58 $142.88 $121.44 71 $109.54 $158.74 $134.94

$102.00 $147.82 $125.65 72 $114.60 $166.09 $141.17

$105.41 $152.78 $129.85 73 $119.79 $173.61 $147.56

$108.82 $157.72 $134.06 74 $125.09 $181.28 $154.09

$112.02 $162.34 $138.00 75 $130.26 $188.78 $160.46

$114.74 $166.28 $141.35 76 $134.97 $195.62 $166.28

$116.73 $169.17 $143.79 77 $137.33 $199.03 $169.17

$118.71 $172.04 $146.24 78 $139.66 $202.41 $172.04

$120.88 $175.19 $148.91 79 $142.21 $206.10 $175.19

$122.96 $178.20 $151.47 80 $144.66 $209.65 $178.20

$125.67 $182.12 $154.80 81 $146.12 $211.77 $180.00

$128.29 $185.92 $158.03 82 $147.46 $213.71 $181.64

$130.81 $189.58 $161.14 83 $148.64 $215.42 $183.11

$133.25 $193.12 $164.15 84 $149.72 $216.99 $184.44

$135.59 $196.51 $167.02 85 $150.65 $218.34 $185.59

$137.81 $199.73 $169.78 86 $151.44 $219.49 $186.57

$139.93 $202.81 $172.38 87 $152.10 $220.44 $187.37

$141.93 $205.70 $174.84 88 $152.61 $221.18 $188.00

$143.79 $208.40 $177.14 89 $152.97 $221.71 $188.45

$145.50 $210.87 $179.24 90 and Over $153.15 $221.96 $188.67

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NON-TOBACCO

Plan A UM1

Plan F UM4

Plan G UM5

FEMALE MALE

Plan A UM1

Plan F UM4

Plan G UM5

UNITED OF OMAHA LIFE INSURANCE COMPANY

MONTHLY RATES*

ZIP CODES: 733, 750-753, 760-761, 774, 776-777, 782, 784, 793-794

$185.32 Through 64 $205.92

$80.70 $116.96 $99.42 65 $84.94 $123.12 $104.65

$80.70 $116.96 $99.42 66 $84.94 $123.12 $104.65

$83.84 $121.52 $103.29 67 $89.20 $129.28 $109.88

$87.14 $126.29 $107.35 68 $93.70 $135.80 $115.42

$90.54 $131.22 $111.54 69 $98.42 $142.63 $121.24

$93.91 $136.08 $115.67 70 $103.18 $149.54 $127.11

$97.20 $140.88 $119.74 71 $108.01 $156.52 $133.05

$100.57 $145.75 $123.89 72 $112.99 $163.76 $139.20

$103.93 $150.64 $128.03 73 $118.11 $171.18 $145.50

$107.30 $155.51 $132.18 74 $123.34 $178.74 $151.93

$110.45 $160.07 $136.07 75 $128.43 $186.13 $158.21

$113.14 $163.96 $139.37 76 $133.08 $192.89 $163.96

$115.10 $166.80 $141.78 77 $135.41 $196.24 $166.80

$117.05 $169.64 $144.19 78 $137.71 $199.58 $169.64

$119.19 $172.73 $146.82 79 $140.22 $203.22 $172.73

$121.24 $175.71 $149.35 80 $142.63 $206.71 $175.71

$123.91 $179.57 $152.63 81 $144.08 $208.81 $177.48

$126.49 $183.32 $155.82 82 $145.39 $210.71 $179.10

$128.98 $186.92 $158.88 83 $146.56 $212.41 $180.55

$131.38 $190.42 $161.85 84 $147.63 $213.95 $181.86

$133.69 $193.76 $164.68 85 $148.54 $215.28 $182.99

$135.88 $196.93 $167.40 86 $149.32 $216.42 $183.96

$137.97 $199.97 $169.96 87 $149.97 $217.35 $184.75

$139.94 $202.82 $172.40 88 $150.48 $218.08 $185.37

$141.78 $205.49 $174.66 89 $150.83 $218.60 $185.81

$143.47 $207.92 $176.73 90 and Over $151.01 $218.85 $186.03

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TOBACCO

Plan A UM1

Plan F UM4

Plan G UM5

FEMALE MALE

Plan A UM1

Plan F UM4

Plan G UM5 ZIP CODES: 733, 750-753, 760-761, 774, 776-777, 782, 784, 793-794

$213.01 Through 64 $236.69

$92.76 $134.44 $114.27 65 $97.63 $141.52 $120.29

$92.76 $134.44 $114.27 66 $97.63 $141.52 $120.29

$96.37 $139.68 $118.73 67 $102.53 $148.59 $126.30

$100.16 $145.16 $123.39 68 $107.70 $156.09 $132.67

$104.07 $150.83 $128.20 69 $113.13 $163.95 $139.35

$107.94 $156.42 $132.96 70 $118.60 $171.88 $146.11

$111.72 $161.93 $137.63 71 $124.14 $179.91 $152.93

$115.60 $167.53 $142.40 72 $129.88 $188.23 $160.00

$119.46 $173.15 $147.17 73 $135.76 $196.76 $167.24

$123.33 $178.75 $151.93 74 $141.77 $205.45 $174.63

$126.96 $183.99 $156.40 75 $147.63 $213.95 $181.86

$130.04 $188.46 $160.19 76 $152.97 $221.71 $188.46

$132.29 $191.73 $162.97 77 $155.64 $225.56 $191.73

$134.54 $194.98 $165.74 78 $158.28 $229.40 $194.98

$137.00 $198.54 $168.76 79 $161.17 $233.58 $198.54

$139.35 $201.96 $171.67 80 $163.95 $237.60 $201.96

$142.42 $206.41 $175.44 81 $165.61 $240.01 $204.00

$145.39 $210.71 $179.10 82 $167.12 $242.20 $205.86

$148.25 $214.85 $182.62 83 $168.46 $244.15 $207.53

$151.01 $218.87 $186.04 84 $169.69 $245.92 $209.03

$153.66 $222.71 $189.29 85 $170.74 $247.45 $210.33

$156.18 $226.36 $192.41 86 $171.64 $248.76 $211.45

$158.59 $229.85 $195.36 87 $172.38 $249.83 $212.35

$160.85 $233.12 $198.16 88 $172.96 $250.67 $213.07

$162.97 $236.19 $200.76 89 $173.37 $251.27 $213.58

$164.90 $238.99 $203.13 90 and Over $173.57 $251.55 $213.82

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NON-TOBACCO

Plan A UM1

Plan F UM4

Plan G UM5

FEMALE MALE

Plan A UM1

Plan F UM4

Plan G UM5

UNITED OF OMAHA LIFE INSURANCE COMPANY

MONTHLY RATES*

ZIP CODES: 770-773, 775

$210.75 Through 64 $234.19

$91.78 $133.01 $113.06 65 $96.60 $140.02 $119.02

$91.78 $133.01 $113.06 66 $96.60 $140.02 $119.02

$95.35 $138.20 $117.47 67 $101.45 $147.02 $124.96

$99.10 $143.62 $122.08 68 $106.56 $154.44 $131.27

$102.97 $149.23 $126.85 69 $111.93 $162.21 $137.88

$106.79 $154.76 $131.55 70 $117.34 $170.06 $144.56

$110.54 $160.21 $136.17 71 $122.83 $178.00 $151.31

$114.37 $165.75 $140.89 72 $128.50 $186.24 $158.30

$118.20 $171.31 $145.61 73 $134.32 $194.68 $165.47

$122.02 $176.85 $150.32 74 $140.27 $203.27 $172.79

$125.62 $182.04 $154.74 75 $146.06 $211.68 $179.93

$128.66 $186.46 $158.50 76 $151.35 $219.36 $186.46

$130.89 $189.70 $161.24 77 $153.99 $223.17 $189.70

$133.11 $192.92 $163.99 78 $156.61 $226.97 $192.92

$135.55 $196.44 $166.97 79 $159.46 $231.11 $196.44

$137.88 $199.82 $169.85 80 $162.21 $235.08 $199.82

$140.92 $204.22 $173.58 81 $163.85 $237.47 $201.84

$143.85 $208.48 $177.21 82 $165.35 $239.63 $203.68

$146.68 $212.58 $180.69 83 $166.68 $241.56 $205.33

$149.41 $216.55 $184.07 84 $167.89 $243.32 $206.82

$152.04 $220.35 $187.29 85 $168.93 $244.83 $208.11

$154.53 $223.96 $190.38 86 $169.82 $246.12 $209.21

$156.91 $227.41 $193.29 87 $170.56 $247.18 $210.11

$159.15 $230.65 $196.06 88 $171.13 $248.01 $210.81

$161.24 $233.69 $198.63 89 $171.53 $248.61 $211.32

$163.16 $236.46 $200.98 90 and Over $171.74 $248.89 $211.56

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TOBACCO

Plan A UM1

Plan F UM4

Plan G UM5

FEMALE MALE

Plan A UM1

Plan F UM4

Plan G UM5 ZIP CODES: 770-773, 775

$242.24 Through 64 $269.18

$105.49 $152.89 $129.96 65 $111.04 $160.94 $136.80

$105.49 $152.89 $129.96 66 $111.04 $160.94 $136.80

$109.60 $158.85 $135.02 67 $116.60 $168.99 $143.63

$113.91 $165.08 $140.33 68 $122.48 $177.52 $150.88

$118.36 $171.53 $145.80 69 $128.66 $186.45 $158.48

$122.75 $177.89 $151.21 70 $134.87 $195.47 $166.16

$127.06 $184.15 $156.52 71 $141.18 $204.60 $173.92

$131.46 $190.52 $161.95 72 $147.70 $214.07 $181.96

$135.86 $196.91 $167.37 73 $154.40 $223.76 $190.19

$140.26 $203.28 $172.78 74 $161.23 $233.65 $198.60

$144.39 $209.24 $177.86 75 $167.89 $243.31 $206.82

$147.89 $214.32 $182.18 76 $173.97 $252.14 $214.32

$150.45 $218.05 $185.33 77 $177.00 $256.52 $218.05

$153.00 $221.75 $188.49 78 $180.01 $260.88 $221.75

$155.80 $225.79 $191.92 79 $183.29 $265.64 $225.79

$158.48 $229.68 $195.23 80 $186.45 $270.21 $229.68

$161.97 $234.74 $199.52 81 $188.34 $272.95 $232.00

$165.35 $239.63 $203.68 82 $190.05 $275.44 $234.11

$168.59 $244.34 $207.69 83 $191.59 $277.66 $236.01

$171.74 $248.91 $211.57 84 $192.98 $279.68 $237.72

$174.75 $253.27 $215.27 85 $194.17 $281.42 $239.20

$177.62 $257.43 $218.82 86 $195.19 $282.90 $240.47

$180.36 $261.39 $222.18 87 $196.04 $284.12 $241.50

$182.93 $265.12 $225.35 88 $196.70 $285.07 $242.31

$185.33 $268.61 $228.31 89 $197.17 $285.75 $242.89

$187.54 $271.79 $231.01 90 and Over $197.40 $286.08 $243.17

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Disclosures

Use this outline to compare benefits and premiums among policies.

Premium Information

We, United of Omaha, can only raise your premium if we raise the premium for all the policies like yours in the same geographic area of the state where you live. Until you are age 90, your premium may change each year. This change will only be made on the first renewal date that coincides with or follows each anniversary of the policy date. Schedules of rates may vary depending upon your policy date.

Household Premium Discount

If you have resided with at least one, but no more than three, other Medicare eligible adults for the past year, or you are

married, and at least one of these other adults or your spouse also owns or is issued a Medicare supplement policy underwritten by United of Omaha or its affiliates, you will be eligible for a household premium discount. The discounted premium will be priced 7% lower than the rates illustrated. Your policy's household premium discount will be removed if your spouse or the other Medicare supplement policyholder chooses to terminate their Medicare supplement policy or he or she no longer resides with you (other than in the case of their death.)

Read Your Policy 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 the United of Omaha Life Insurance Company.

Right to Return Policy

If you find that you are not satisfied with your policy, you may return it to United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, NE 68175. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

Policy Replacement

If you are replacing another health insurance policy or other health insurance coverage, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

Exceptions and Limitations We will not pay for:

(a) services for which a charge is normally not made when there is no insurance;

(b) expense incurred before the policy date; or (c) expense incurred which is paid for by Medicare.

Refund of Unearned Premium

In the event of cancellation or death, we will promptly return the unearned portion of any premium paid. Termination of coverage will not affect any claim originating while this policy is in force.

Notice

The policy may not fully cover all of your medical costs. Neither United of Omaha 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 "Medicare & 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. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded.

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*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.

**$0 indicates your liability for covered charges. You are responsible for all other non-covered charges.

Services Medicare Pays Plan A Pays You Pay

HOSPITALIZATION*

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

First 60 days All but $1,068 $0 $1,068 (Part A Deductible)

61^st through 90^th day All but $267 a day $267 a day $0**

91^st day and after:

While using 60 lifetime reserve days All but $534 a day $534 a day $0**

Once lifetime reserve days are used:

Additional 365 days $0

100% of Medicare

Eligible Expenses $0**+

Beyond the additional 365 days $0 $0 All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0**

21^st through 100^th day All but $133.50 a day $0 Up to $133.50 a day

101^st day and after $0 $0 All costs

BLOOD

First 3 pints $0 3 pints $0**

Additional amounts 100% $0 $0**

HOSPICE CARE

Available as long as your doctor certifies you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care

$0 Balance

+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

from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

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PLAN A

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

* Once you have been billed $135 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.

**$0 indicates your liability for covered charges. You are responsible for all other non-covered charges.

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 $135 of Medicare Approved Amounts* $0 $0 $135 (Part B Deductible)

Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0**

Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs BLOOD

First 3 pints $0 All costs $0**

Next $135 of Medicare Approved Amounts* $0 $0 $135 (Part B Deductible)

Remainder of Medicare Approved Amounts 80% 20% $0**

CLINICAL LABORATORY SERVICES—TESTS FOR

DIAGNOSTIC SERVICES 100% $0 $0**

PARTS A AND B HOME HEALTH CARE—MEDICARE APPROVED

SERVICES

Medically necessary skilled care services and medical

supplies 100% $0 $0**

Durable medical equipment

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** $0 indicates your liability for covered charges. You are responsible for all other non-covered charges.

Services Medicare Pays Plan F Pays You Pay

HOSPITALIZATION*

First 60 days All but $1,068 $1,068 (Part A Deductible) $0**

Additional 365 days $0 100% of Medicare

Eligible Expenses

$0**+

21^st through 100^th day All but $133.50 a day Up to $133.50 a day $0**

BLOOD

HOSPICE CARE

$0 Balance

+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

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PLAN F

*Once you have been billed $135 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 F 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 $135 of Medicare Approved Amounts* $0 $135 (Part B Deductible) $0**

Remainder of Medicare Approved Amounts Generally80% Generally20% $0**

Part B Excess Charges (above Medicare Approved Amounts) $0 100% $0**

BLOOD

Next $135 of Medicare Approved Amounts* $0 $135 (Part B Deductible) $0**

PARTS A and B HOME HEALTH CARE—MEDICARE APPROVED

SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0**

First $135 of Medicare Approved Amounts* $0 $135 (Part B Deductible) $0**

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 $0 $0 $250

Remainder of charges $0 80% to a lifetime

Maximum Benefit of

$50,000

20% and amounts over the $50,000 lifetime Maximum Benefit

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Services Medicare Pays Plan G Pays You Pay

HOSPITALIZATION*

First 60 days All but $1,068 $1,068 (Part A Deductible) $0**

Additional 365 days $0 100% of Medicare Eligible

Expenses

$0**+

21^st through 100^th day All but $133.50 a day Up to $133.50 a day $0**

BLOOD

HOSPICE CARE

$0 Balance

+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

(15)

PLAN G

*Once you have been billed $135 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.

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

Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0**

Part B Excess Charges (above Medicare Approved Amounts) $0 80% 20%

BLOOD

Next $135 of Medicare Approved Amounts* $0 $0 $135 (Part B Deductible)

PARTS A AND B HOME HEALTH CARE—MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0**

HOME HEALTH CARE—AT-HOME RECOVERY SERVICES NOT COVERED BY MEDICARE Home care certified by your doctor for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan

Benefit for each visit $0 Actual charges to $40 a visit Balance

Number of visits covered (must be received within 8 weeks of last Medicare approved visit)

$0 Up to the number of Medicare approved visits, not to exceed 7 each week

Balance

Calendar year maximum $0 $1,600 Balance

(16)

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 $0 $0 $250

Remainder of charges $0 80% to a lifetime

Maximum

Benefit of $50,000

20% and amounts over the $50,000 lifetime Maximum Benefit