UNITED OF OMAHA LIFE INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGE BENEFIT PLANS A, F, G, AND M These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan “A.” be available in your state. See Outlines of Coverage sections for details about ALL plans. Basic Benefits: Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. require insureds to pay a portion of Part B coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. Plan B Plan C Plan D Plan K Plan L Plan A Plan F F* Plan G Plan M Basic, Basic, Basic, Basic, Basic, Basic, Hospitalization Hospitalization Basic, including including including including including including and preventive and preventive including 100% 100% 100% 100% Part 100% 100% 100% care paid at care paid at Part B co- Part B co- Part B co- Part B co- Part B coPart B coB co100%; other 100%; other insurance insurance insurance insurance insurance * insurance insurance basic benefits basic benefits paid at 50% paid at 75%

Part A Deductible

Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible

Foreign Travel Emergency

Skilled Nursing Facility Coinsurance Part A Deductible

Foreign Travel Emergency

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

Skilled Nursing Facility Coinsurance Part A Deductible

50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance

50% Part A Deductible

75% Part A Deductible

Part B Excess (100%) Foreign Travel Emergency

Plans K, L, and N

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

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

Foreign Travel Emergency Out-of-pocket limit $4,660; paid at 100% after limit reached

Some plans may not

Foreign Travel Emergency

Out-of-pocket limit $2,330; paid at 100% after limit reached *Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,070 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,070. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plans' separate foreign travel emergency deductible. CP51 1 U8183_GA_0012

MONTHLY NON-TOBACCO PREMIUMS* ZIP CODES: 304-307, 310, 312, 315-319, 398

FEMALE MALE Plan A Plan F Plan G Plan M Issue Plan A Plan F Plan G UM20 UM23 UM24 UM30 Age UM20 UM23 UM24 933.68 1,353.18 1,129.14 1,075.72 1,471.62 1,227.95 Thru 64** 1,015.42 93.37 135.32 112.91 107.58 101.54 147.16 122.79 65 97.30 141.02 117.66 112.11 106.97 155.04 129.36 66 101.30 146.79 122.48 116.70 112.48 163.02 136.02 67 105.25 152.54 127.28 121.27 117.96 170.96 142.65 68 109.17 158.22 132.03 125.80 123.31 178.71 149.11 69 113.01 163.78 136.65 130.20 128.43 186.13 155.30 70 115.95 168.04 140.20 133.58 132.43 191.93 160.15 71 118.77 172.13 143.63 136.84 136.20 197.40 164.70 72 121.46 176.02 146.87 139.93 139.67 202.42 168.89 73 123.97 179.67 149.91 142.84 142.73 206.85 172.60 74 126.29 183.03 152.72 145.51 145.33 210.60 175.73 75 128.46 186.17 155.35 148.00 147.38 213.59 178.23 76 130.57 189.22 157.89 150.44 149.06 216.04 180.26 77 132.67 192.28 160.44 152.87 150.60 218.26 182.12 78 134.80 195.35 163.01 155.30 151.93 220.19 183.72 79 136.90 198.41 165.55 157.73 153.01 221.76 185.04 80 138.95 201.38 168.02 160.09 153.88 223.00 186.08 81 140.85 204.12 170.32 162.28 154.63 224.10 186.99 82 142.58 206.64 172.41 164.28 155.27 225.02 187.76 83 144.16 208.93 174.33 166.11 155.78 225.77 188.38 84 145.55 210.94 176.01 167.70 156.18 226.36 188.87 85 146.75 212.67 177.46 169.09 156.49 226.81 189.25 86 147.72 214.09 178.63 170.20 156.72 227.13 189.52 87 148.46 215.14 179.52 171.04 156.86 227.33 189.68 88 148.93 215.83 180.08 171.59 156.93 227.43 189.78 89 149.09 216.08 180.30 171.79 156.94 227.46 189.79 90+ *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.

RP51.12.B-GA

Plan M UM30 1,169.89 116.99 123.26 129.60 135.91 142.07 147.97 152.59 156.93 160.92 164.45 167.43 169.80 171.74 173.52 175.05 176.30 177.29 178.15 178.89 179.48 179.95 180.32 180.56 180.73 180.82 180.83

To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. **Only individuals who are Disabled or have End Stage Renal Disease are eligible for coverage under the age of 65.

2

U8183_GA_0012

MONTHLY TOBACCO PREMIUMS* ZIP CODES: 304-307, 310, 312, 315-319, 398

FEMALE MALE Plan A Plan F Plan G Plan M Issue Plan A Plan F Plan G UM20 UM23 UM24 UM30 Age UM20 UM23 UM24 1,073.19 1,555.38 1,297.87 1,236.46 1,691.52 1,411.43 Thru 64** 1,167.15 107.32 155.54 129.79 123.65 116.71 169.15 141.14 65 111.84 162.09 135.24 128.86 122.95 178.20 148.69 66 116.43 168.73 140.79 134.14 129.29 187.37 156.35 67 120.98 175.34 146.29 139.39 135.58 196.50 163.97 68 125.49 181.87 151.76 144.59 141.74 205.41 171.39 69 129.90 188.25 157.07 149.65 147.62 213.95 178.51 70 133.27 193.15 161.15 153.54 152.22 220.61 184.08 71 136.52 197.85 165.09 157.29 156.55 226.89 189.31 72 139.60 202.32 168.82 160.84 160.54 232.66 194.13 73 142.49 206.52 172.31 164.19 164.06 237.76 198.39 74 145.16 210.38 175.54 167.25 167.04 242.07 201.99 75 147.65 213.99 178.56 170.11 169.40 245.51 204.86 76 150.08 217.50 181.48 172.92 171.33 248.32 207.20 77 152.50 221.02 184.42 175.71 173.10 250.87 209.34 78 154.94 224.54 187.37 178.51 174.63 253.09 211.17 79 157.35 228.06 190.29 181.30 175.87 254.90 212.69 80 159.71 231.47 193.13 184.01 176.87 256.33 213.89 81 161.89 234.62 195.77 186.52 177.74 257.58 214.93 82 163.88 237.52 198.18 188.83 178.47 258.65 215.82 83 165.70 240.15 200.38 190.93 179.05 259.51 216.53 84 167.30 242.46 202.31 192.76 179.52 260.19 217.09 85 168.67 244.45 203.97 194.35 179.88 260.70 217.53 86 169.80 246.08 205.33 195.64 180.14 261.07 217.84 87 170.64 247.29 206.35 196.60 180.30 261.30 218.03 88 171.18 248.08 206.99 197.23 180.38 261.41 218.14 89 171.37 248.37 207.24 197.46 180.40 261.45 218.14 90+ *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.

RP51.12.B-GA

Plan M UM30 1,344.70 134.47 141.68 148.96 156.22 163.29 170.09 175.39 180.38 184.96 189.02 192.45 195.18 197.40 199.44 201.20 202.64 203.78 204.77 205.62 206.30 206.84 207.26 207.54 207.74 207.83 207.85

To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. **Only individuals who are Disabled or have End Stage Renal Disease are eligible for coverage under the age of 65.

3

U8183_GA_0012

MONTHLY NON-TOBACCO PREMIUMS* ZIP CODES: 300-303, 308-309, 311, 313-314, 399

Plan A UM20 1,021.55 102.16 106.46 110.83 115.16 119.45 123.65 126.86 129.95 132.89 135.64 138.18 140.55 142.86 145.16 147.48 149.78 152.02 154.10 156.00 157.73 159.25 160.56 161.63 162.43 162.94 163.12

MALE FEMALE Plan F Plan G Plan M Issue Plan A Plan F Plan G UM23 UM24 UM30 Age UM20 UM23 UM24 1,480.54 1,235.41 1,176.97 1,610.13 1,343.52 Thru 64** 1,110.99 148.06 123.54 117.70 111.10 161.01 134.35 65 154.29 128.74 122.66 117.04 169.63 141.54 66 160.61 134.01 127.68 123.06 178.36 148.83 67 166.90 139.25 132.68 129.06 187.05 156.08 68 173.12 144.46 137.64 134.92 195.53 163.15 69 179.19 149.51 142.45 140.52 203.65 169.92 70 183.85 153.40 146.16 144.89 209.99 175.22 71 188.33 157.14 149.72 149.02 215.97 180.20 72 192.58 160.70 153.10 152.82 221.47 184.79 73 196.58 164.02 156.29 156.16 226.32 188.84 74 200.26 167.10 159.21 159.00 230.42 192.27 75 203.69 169.97 161.93 161.25 233.69 195.00 76 207.03 172.75 164.60 163.09 236.37 197.23 77 210.38 175.54 167.26 164.77 238.80 199.27 78 213.74 178.35 169.92 166.23 240.91 201.01 79 217.08 181.13 172.57 167.41 242.63 202.45 80 220.33 183.84 175.15 168.36 243.99 203.59 81 223.33 186.35 177.55 169.18 245.19 204.59 82 226.09 188.64 179.74 169.89 246.20 205.43 83 228.60 190.74 181.74 170.44 247.02 206.11 84 230.80 192.57 183.49 170.88 247.67 206.64 85 232.69 194.16 185.00 171.22 248.15 207.07 86 234.23 195.45 186.22 171.47 248.51 207.36 87 235.39 196.42 187.14 171.63 248.73 207.53 88 236.14 197.03 187.74 171.70 248.83 207.64 89 236.42 197.27 187.95 171.72 248.87 207.65 90+ *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.

Plan M UM30 1,280.00 128.00 134.86 141.80 148.71 155.44 161.90 166.95 171.70 176.06 179.93 183.19 185.79 187.91 189.85 191.52 192.89 193.97 194.92 195.73 196.37 196.89 197.29 197.56 197.74 197.83 197.85

To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. **Only individuals who are Disabled or have End Stage Renal Disease are eligible for coverage under the age of 65. RP51.12.B-GA

4

U8183_GA_0012

MONTHLY TOBACCO PREMIUMS* ZIP CODES: 300-303, 308-309, 311, 313-314, 399

Plan A UM20 1,174.20 117.42 122.37 127.39 132.37 137.30 142.12 145.82 149.37 152.74 155.91 158.83 161.55 164.20 166.85 169.52 172.16 174.74 177.13 179.30 181.29 183.04 184.55 185.78 186.70 187.29 187.50

FEMALE MALE Plan F Plan G Plan M Issue Plan A Plan F Plan G UM23 UM24 UM30 Age UM20 UM23 UM24 1,701.77 1,420.02 1,352.83 1,850.72 1,544.27 Thru 64** 1,277.00 170.18 142.00 135.29 127.70 185.07 154.43 65 177.34 147.97 140.99 134.52 194.97 162.69 66 184.61 154.04 146.76 141.45 205.01 171.06 67 191.84 160.06 152.51 148.34 215.00 179.40 68 198.98 166.04 158.20 155.08 224.74 187.53 69 205.97 171.86 163.74 161.51 234.08 195.31 70 211.32 176.32 168.00 166.54 241.37 201.40 71 216.48 180.63 172.10 171.29 248.25 207.13 72 221.36 184.71 175.98 175.65 254.56 212.40 73 225.95 188.53 179.64 179.50 260.14 217.06 74 230.18 192.06 183.00 182.76 264.86 221.00 75 234.13 195.37 186.12 185.34 268.61 224.14 76 237.97 198.56 189.19 187.46 271.69 226.70 77 241.82 201.77 192.25 189.39 274.48 229.04 78 245.68 205.00 195.31 191.07 276.91 231.05 79 249.52 208.20 198.36 192.43 278.89 232.71 80 253.26 211.31 201.33 193.51 280.45 234.02 81 256.70 214.20 204.08 194.46 281.83 235.16 82 259.87 216.83 206.60 195.27 282.99 236.13 83 262.75 219.24 208.90 195.90 283.93 236.91 84 265.28 221.35 210.91 196.42 284.67 237.52 85 267.46 223.17 212.64 196.81 285.23 238.01 86 269.24 224.65 214.05 197.10 285.64 238.34 87 270.57 225.77 215.10 197.27 285.89 238.55 88 271.43 226.47 215.79 197.36 286.01 238.67 89 271.75 226.74 216.04 197.37 286.06 238.68 90+ *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.

Plan M UM30 1,471.26 147.13 155.01 162.98 170.93 178.66 186.09 191.90 197.36 202.37 206.81 210.56 213.55 215.98 218.22 220.14 221.71 222.96 224.05 224.98 225.71 226.31 226.77 227.08 227.29 227.39 227.41

To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. **Only individuals who are Disabled or have End Stage Renal Disease are eligible for coverage under the age of 65. RP51.12.B-GA

5

U8183_GA_0012

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. Risk Class Rating If, according to our underwriting standards, you are overweight or underweight for your height, you will be considered to be a greater insurable risk. In such a case, your premium will be priced either as Class I 10% or Class II - 20% higher than the rates illustrated, based on your Body Mass Index (BMI) reading. Risk class rating will not be applicable when you apply for coverage during an open enrollment or guaranteed issue period. Household Premium Discount If you 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).

DP2B

Read Your Policy Very Carefully This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. Right to Return 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, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. 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.

6

U8183_GA_0012

PLAN A MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Services Medicare Pays Plan A Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,156 $0 $1,156 (Part A Deductible) st th 61 through 90 day All but $289 a day $289 a day $0 91st day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare $0** Eligible Expenses 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 21st through 100th day All but $144.50 a day $0 Up to $144.50 a day 101st day and after

$0

$0

All costs

BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness.

$0 3 pints $0 100% $0 $0 All but very limited Medicare copayment/ $0 copayment/coinsurance coinsurance for outpatient drugs and inpatient respite care **NOTICE: When your Medicare Part A hospital benefits are During this time the hospital is prohibited from billing you exhausted, the insurer stands in the place of Medicare and will pay for the balance based on any difference between its whatever amount Medicare would have paid for up to an additional billed charges and the amount Medicare would have 365 days as provided in the policy/certificate's "Core Benefits." paid.

BC51

7

U8183_GA_0012

PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 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 $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts Part B Excess Charges (above Medicare Approved Amounts) BLOOD First 3 pints Next $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES

Medicare Pays

Plan A Pays

You Pay

$0 Generally 80% $0

$0 Generally 20% $0

$140 (Part B Deductible) $0 All costs

$0 $0

All costs $0

$0 $140 (Part B Deductible)

80%

20%

$0

100%

$0

$0

100%

$0

$0

$0 80%

$0 20%

$140 (Part B Deductible) $0

PARTS A AND B HOME HEALTH CARE—MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

BC51

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U8183_GA_0012

PLANS F AND G MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Services Medicare Pays Plan F Pays You Pay Plan G Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,156 $1,156 (Part A $0 $1,156 (Part A $0 Deductible) Deductible) 61st through 90th day All but $289 a day $289 a day $0 $289 a day $0 st 91 day and after: While using 60 lifetime reserve All but $578 a day $578 a day $0 $578 a day $0 days Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare $0** 100% of Medicare $0** Eligible Expenses Eligible Expenses Beyond the additional 365 days $0 $0 All costs $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 $0 $0 st th 21 through 100 day All but $144.50 a day Up to $144.50 a day $0 Up to $144.50 a day $0 101st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $0 $0 All but very limited Medicare $0 Medicare $0 HOSPICE CARE You must meet Medicare's requirements, copayment/coinsuran copayment/coinsuran copayment/coinsura including a doctor's certification of terminal ce for outpatient ce nce illness. drugs and inpatient respite care **NOTICE: When your Medicare Part A hospital benefits are During this time the hospital is prohibited from billing you exhausted, the insurer stands in the place of Medicare and will pay for the balance based on any difference between its whatever amount Medicare would have paid for up to an additional billed charges and the amount Medicare would have 365 days as provided in the policy/certificate's "Core Benefits." paid. BC51

9

U8183_GA_0012

PLANS F AND G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 Plan G 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 $0 $140 (Part B $0 $0 $140 (Part B First $140 of Medicare Approved Amounts* Deductible) Deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Generally 20% $0 100% $0 100% $0 $0 Part B Excess Charges (above Medicare Approved Amounts) BLOOD First 3 pints Next $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES

$0 $0

All costs $0

80%

All costs $140 (Part B Deductible) 20%

$0

20%

$0 $140 (Part B Deductible) $0

100%

$0

$0

$0

$0

$0 $0

PARTS A AND B HOME HEALTH CARE—MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

BC51

100%

$0

$0

$0

$0

$0

$140 (Part B Deductible) 20%

$0

$0

$0

20%

$140 (Part B Deductible) $0

80%

10

U8183_GA_0012

PLANS F AND G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR OTHER BENEFITS – NOT COVERED BY MEDICARE Services Medicare Pays Plan F Pays You Pay FOREIGN TRAVEL—NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA $0 $0 $250 First $250 each calendar year Remainder of charges $0 80% to a lifetime 20% and amounts Maximum Benefit over the $50,000 of $50,000 lifetime Maximum Benefit

BC51

11

Plan G Pays

You Pay

$0 80% to a lifetime Maximum Benefit of $50,000

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

U8183_GA_0012

PLAN M MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Services Medicare Pays Plan M Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,156 $578 (50% of Part A $578 (50% of Part A deductible) Deductible) 61st through 90th day All but $289 a day $289 a day $0 st 91 day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare $0** Eligible Expenses 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

21st through 100th day 101st day and after

All approved amounts $0 All but $144.50 a day Up to $144.50 a day $0 $0

$0 $0 All costs

BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness.

$0 3 pints $0 100% $0 $0 All but very limited Medicare copayment $0 copayment/ /coinsurance coinsurance for outpatient drugs and inpatient respite care **NOTICE: When your Medicare Part A hospital benefits are exhausted, the During this time the hospital is prohibited from billing you for the insurer stands in the place of Medicare and will pay whatever amount Medicare balance based on any difference between its billed charges and the would have paid for up to an additional 365 days as provided in the amount Medicare would have paid. policy/certificate's "Core Benefits."

BC51

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U8183_GA_0012

PLAN M MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 M 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 $140 of Medicare Approved Amounts* $0 $0 $140 (Part B Deductible) Remainder of Medicare Approved Amounts Generally 80% Generally $0 20% $0 All costs $0 Part B Excess Charges (above Medicare Approved Amounts) BLOOD First 3 pints Next $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts CLINICAL LABORATORY SERVICES—TESTS FOR DIAGNOSTIC SERVICES

BC51

13

$0 $0

All costs $0

$0 $140 (Part B Deductible)

80%

20%

$0

100%

$0

$0

U8183_GA_0012

PLAN M MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR PARTS A AND B Services

Medicare Pays

HOME HEALTH CARE—MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $140 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

Plan M Pays

You Pay

100%

$0

$0

$0 80%

$0 20%

$140 (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 Remainder of charges

BC51

$0 $0

$0 $250 80% to a lifetime 20% and amounts over the $50,000 lifetime Maximum Benefit Maximum Benefit of $50,000

14

U8183_GA_0012